North Carolina Department of Health and Human …As a part of the State of North Carolina (NC or...

Population Profiles.docx November 2017Prepared by Mercer Government Human Services Consulting

North Carolina Department of Health andHuman Services Division of Health Benefits

Medicaid TransformationPopulation Profiles

November 9, 2017


TABLE OF CONTENTS1 Introduction ...........................................................................................................................................3

Content of the Population Profiles ........................................................................................................ 31.11.1.1 Data Extracts ................................................................................................................................ 31.1.2 Geographic Considerations ........................................................................................................... 4

Caveats ................................................................................................................................................ 51.2

2 Covered Populations ..............................................................................................................................6 Population Overview ............................................................................................................................ 62.1 Population Grouping Logic.................................................................................................................... 62.2

2.2.1 Standard Plan (Non-Duals) ............................................................................................................ 62.2.2 Foster Children and Adopted Children .......................................................................................... 72.2.3 BH I/DD Tailored Plan (Non-Dual and Dual Eligibles) ..................................................................... 82.2.4 Non-Dual LTSS Population ............................................................................................................. 82.2.5 Dual Eligibles ................................................................................................................................ 92.2.6 Permanently Excluded .................................................................................................................. 9

3 Covered Services .................................................................................................................................. 10

4 Data Adjustments ................................................................................................................................. 12 Completion Factors ............................................................................................................................ 124.1 Graduate Medical Expense (GME) Adjustment ................................................................................... 134.2 Cost Settlements ................................................................................................................................ 134.3 Hospital Supplemental Payments ....................................................................................................... 144.4 Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (ICF/IID) 144.5 Non-Emergency Medical Transportation (NEMT) Adjustment ............................................................. 144.6 LME/MCO Adjustments ...................................................................................................................... 154.7

4.7.1 Patient Liability Adjustment ........................................................................................................ 154.7.2 Payments Made Outside of the Claims System ............................................................................ 16

Pharmacy Rebates .............................................................................................................................. 164.8

5 Base Data Summarization Next Steps .................................................................................................... 17

6 Population Profile Data Exhibits Overview ............................................................................................ 18

7 Population Group Exhibits .................................................................................................................... 19 SFY 2015 Population Group Exhibits ................................................................................................... 207.1

7.1.1 SFY 2015 Standard Plan (Non-Duals) ........................................................................................... 217.1.2 SFY 2015 Foster Children and Adopted Children (Non-Duals) ...................................................... 317.1.3 SFY 2015 Behavioral Health Intellectual/Developmental Disability Tailored Plan (Non-Duals andDuals) ................................................................................................................................................... 337.1.4 SFY 2015 Non-Dual Long Term Services and Supports Population ............................................... 437.1.5 SFY 2015 Dual Eligibles................................................................................................................ 47

SFY 2016 Population Group Exhibits ................................................................................................... 507.27.2.1 SFY 2016 Standard Plan (Non-Duals) ........................................................................................... 517.2.2 SFY 2016 Foster Children and Adopted Children (Non-Duals) ...................................................... 617.2.3 SFY 2016 Behavioral Health Intellectual/Developmental Disability Tailored Plan (Non-Duals andDuals) ................................................................................................................................................... 637.2.4 SFY 2016 Non-Dual Long Term Services and Supports Population ............................................... 737.2.5 SFY 2016 Dual Eligibles................................................................................................................ 77

8 Regional Exhibits .................................................................................................................................. 80


SFY 2015 Regional Exhibits ................................................................................................................. 818.18.1.1 SFY 2015 Standard Plan (Non-Duals) ........................................................................................... 828.1.2 SFY 2015 Foster Children and Adopted Children (Non-Duals) ...................................................... 908.1.3 SFY 2015 Behavioral Health Intellectual/Developmental Disability Tailored Plan (Non-Duals andDuals) ................................................................................................................................................... 988.1.4 SFY 2015 Non-Dual Long Term Services and Supports Population ............................................. 1068.1.5 SFY 2015 Dual Eligibles.............................................................................................................. 114

SFY 2016 Regional Exhibits ............................................................................................................... 1228.28.2.1 SFY 2016 Standard Plan (Non-Duals) ......................................................................................... 1238.2.2 SFY 2016 Foster Children and Adopted Children (Non-Duals) .................................................... 1318.2.3 SFY 2016 Behavioral Health Intellectual/Developmental Disability Tailored Plan (Non-Duals andDuals) ................................................................................................................................................. 1398.2.4 SFY 2016 Non-Dual Long Term Services and Supports Population ............................................. 1478.2.5 SFY 2016 Dual Eligibles.............................................................................................................. 155

Appendix A — BH I/DD Tailored Plan Diagnosis Criteria .............................................................................. 163I/DD Default Diagnosis ................................................................................................................................. 164SED Diagnosis (Ages 0-17.99) ....................................................................................................................... 166SPMI Diagnosis (Ages 18+) ........................................................................................................................... 171SUD Diagnosis Code List............................................................................................................................... 173

Appendix B — Category of Service (COS) Mapping Logic .............................................................................. 175COS Mapping Logic ...................................................................................................................................... 176


1 INTRODUCTIONAs a part of the State of North Carolina (NC or State) Medicaid transformation efforts, Mercer GovernmentHuman Services Consulting (Mercer), part of Mercer Health & Benefits LLC, has completed an analysis of claimsand encounter data for the State Medicaid and NC Health Choice program to create cost profiles for theproposed managed care program design1. This data summarization includes experience for services coveredunder the State fee-for-service (FFS) program, as well as behavioral health (BH) services covered under theMedicaid BH managed care program currently operated by the Local Management Entity/Managed CareOrganizations (LME/MCOs).

The intent of the Population Profiles data report is to summarize historical data for purposes of providingtransparency into the current program costs and utilization by covered population cohorts for potential PrepaidHealth Plans (PHPs) and other interested stakeholders. Specifically, the report includes information on the costand utilization patterns of Medicaid and NC Health Choice eligibles by region, population, age group, andcategory of service (COS). The report provides context as to program scale, and cost and utilization associatedwith specific populations and services.

Mercer was instructed to make assumptions as needed in this document that are consistent with the proposedprogram design for Medicaid managed care released by the NC Department of Health and Human Services(DHHS) in August, elements of which may require additional legislative authority from the North CarolinaGeneral Assembly and/or waiver authority from CMS, and changes in those policies would change componentsof this analysis.

Content of the Population Profiles1.1This data analysis was evaluated for the following time periods on a date of service basis:· July 1, 2014 through June 30, 2015 (State Fiscal Year (SFY) 2015)· July 1, 2015 through June 30, 2016 (SFY 2016)

Please note the following concerning this report.

1.1.1 Data ExtractsMercer has relied upon and utilized the following available data extracts to summarize the eligibility, cost andutilization information.· FFS claims data, provided by the State, from the State Medicaid management information system (MMIS)

responsible for claim adjudication (NC Tracks).· BH encounter data provided to Mercer directly from the LME/MCOs.· Cost information related to Non-Emergency Medical Transportation (NEMT) services billed outside of NC

Tracks.· Supplemental information supplied by the State and LME/MCOs used to support the cost adjustments

outlined in Section 4.· The member month (MM) information reflected in Section 6 of this report is derived from the number of

beneficiaries identified in the member extract file provided to Mercer by the State in May 2017.

These data sources will be used to support future capitation rate development. Future analyses will considerdata through 2017 and into 2018 as well.

1 North Carolina’s Proposed Program Design for Medicaid Managed Care, August 2017,https://files.nc.gov/ncdhhs/documents/files/MedicaidManagedCare_ProposedProgramDesign_REVFINAL_20170808.pdf

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1.1.2 Geographic ConsiderationsMercer also included regional breakouts to allow for evaluation of the differences in cost and utilization acrossthe State. Table 1 outlines the counties included in each of the six proposed PHP regions. Figure 1 illustrates thePHP regions in map format.

Table 1: List of Counties in PHP RegionsPHP Regions CountiesRegion 1 Avery, Buncombe, Burke, Caldwell, Cherokee, Clay, Graham, Haywood, Henderson, Jackson,

Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, YanceyRegion 2 Alleghany, Ashe, Davidson, Davie, Forsyth, Guilford, Randolph, Rockingham, Stokes, Surry,

Watauga, Wilkes, YadkinRegion 3 Alexander, Anson, Cabarrus, Catawba, Cleveland, Gaston, Iredell, Lincoln, Mecklenburg, Rowan,

Stanly, UnionRegion 4 Alamance, Caswell, Chatham, Durham, Franklin, Granville, Johnston, Nash, Orange, Person, Vance,

Wake, Warren, WilsonRegion 5 Bladen, Brunswick, Columbus, Cumberland, Harnett, Hoke, Lee, Montgomery, Moore, New

Hanover, Pender, Richmond, Robeson, Sampson, ScotlandRegion 6 Beaufort, Bertie, Camden, Carteret, Chowan, Craven, Currituck, Dare, Duplin, Edgecombe, Gates,

Greene, Halifax, Hertford, Hyde, Jones, Lenoir, Martin, Northampton, Onslow, Pamlico,Pasquotank, Perquimans, Pitt, Tyrrell, Washington, Wayne

Figure 1: Map of PHP Regions

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Caveats1.2The users of these data summaries are cautioned that direct comparisons cannot be made between theinformation in these summaries and raw claims data and other DHHS reports. Mercer applied adjustments tothe raw data received. Please refer to Section 4 for adjustments reflected in the Population Profiles data exhibitsand Section 5 for adjustments planned for future analysis.

Mercer has used and relied upon eligibility, claims, encounter and supplemental data and information suppliedby both the State and the LME/MCOs. Aforementioned parties are solely responsible for the validity andcompleteness of these supplied data and information. Mercer has reviewed the summarized data in compliancewith the Actuarial Standard of Practice (ASOP) on data quality (ASOP 23), which included checks for:completeness of data, accuracy of the data and consistency of data across data sources and years. However,Mercer did not perform a complete audit.

The users of these data summaries are cautioned against relying solely on the data contained herein. The Stateand Mercer provide no guarantee, either written or implied, that this document is 100% accurate or error-free.The content of these data summaries may also be subject to change pending additional guidance from the Stateon final data summarization logic.

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2 COVERED POPULATIONSThe data exhibits in Section 6 are summarized according to the population groups identified in section 2.1 and2.2 below. In order to identify the population groupings, eligibility information is attached to the claims data perthe member extract file.

Population Overview2.1The information in this report was structured to segment populations based on the DHHS’ proposed managedcare phase-in timeline. As proposed, initial program implementation would enroll all non-dual beneficiaries intothe Standard Plan who are otherwise not eligible for a tailored plan and/or otherwise excluded or delayed assummarized below. DHHS has proposed to phase-in the remaining covered populations over a five year period.See Table 2 below for the managed care population grouping utilized for this report.

Table 2: Managed Care Population GroupingsPopulationStandard Plan

Foster Children and Adopted Children

Behavioral Health (BH) and Intellectual/Developmental Disability (I/DD) Tailored Plan (includingboth non-dual and dual eligibles)Medicaid-only beneficiaries receiving long-stay nursing home servicesMedicaid-only Community Alternatives for Children (CAP/C) waiver beneficiariesMedicaid-only Community Alternatives for Disabled Adults (CAP/DA) waiver beneficiariesDual Eligibles

Population Grouping Logic2.2As mentioned above, Mercer summarized the claims and member months by population grouping. To define thepopulation groups, Mercer leveraged program aid code information, 5-character eligibility code information andDual and Medically Needy status from the State’s eligibility system. The sections below provide detail regardingthe eligibility fields used to define the various population groups. Cost and utilization associated with Tribalmembers have not been separately identified nor excluded for purposes of these data summaries.

Note that beneficiaries may be categorized into multiple population groups if they switched eligibility categoriesduring the year. Claims and eligibility data for a given month were summarized into a population group based onthe earliest record in that month. The populations listed below are mutually exclusive such that costs andutilization were not categorized under more than one population grouping per month.

2.2.1 Standard Plan (Non-Duals)The Standard Plan population includes cost and utilization for non-dual beneficiaries summarized by thefollowing population groupings outlined in Table 3 below. Costs associated with delivery events are broken outseparately in anticipation of development of a separate capitation payment (also known as a kick payment) forthese services. Where applicable, cost and utilization information was also summarized for the following agegroups:· Newborn: Age <1.00· Child: Age 1-20.99· Adult: Age 21+

Table 3: Standard Plan Population Criteria

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Population Group Detailed Population Group Program Aid Code/Eligibility Code

Aged, Blind, Disabled (ABD) Aged MAABN, MAACY, MAAMN , MAANN, MAAQN, MAAQY, SAABN,SAACN, SAACY, SAAQN, SAAQY

Blind MABBN, MABCY, MABMN, MABNN, MABQN, MABQY

Disabled MADBN, MADCY, MADMN, MADNN, MADQN, MADQY, SADBN,SADCN, SADCY, SADQN, SADQY

Temporary Assistance forNeedy Families (TANF) andOther RelatedChildren/Adults

Aid to Families withDependent Children (AFDC)

AAFCN, AAFCY

Other Children MAFCN, MAFMN, MAFNN

Pregnant Women MPWNN

Infants and Children MICNN

Breast and Cervical Cancer(BCC)

MAFWN

Legal Aliens (Full Medicaid) Eligibility codes with a fourth character of G, P, I, or T

NC Health Choice (NCHC) NCHC MICAN, MICJN, MICKN, MICSN

NCHC — Extended Coverage MICLN

Medicaid-Children's HealthInsurance Program (M-CHIP)

N/A MIC1N

Maternity/Delivery N/A Cost summarized for the month of delivery, flagged byidentifying the delivery event using the following logic: CurrentProcedural Terminology (CPT) codes: 59400-59410, 59510-59515, 59610-59622 OR Diagnosis-Related Groups (DRG) 765-768, 774-775 OR ICD-9 codes: 650 OR the following must havea 5th digit equal to 1 or 2: 640-676; International Classificationof Diseases (ICD)-10 codes have been mapped from ICD-9.

Note 1: For specific program eligibility requirements, refer to the NC Basic Medicaid Income Eligibility Chart.2

Note 2: NCHC extended coverage is optional coverage for beneficiaries at 211-225% FPL; beneficiaries may remain on NCHealth Choice for a period not to exceed one year.3

2.2.2 Foster Children and Adopted ChildrenTable 4 outlines the eligibility information used to summarize cost and utilization for the foster children andadopted children population. Summaries outlined in section 6 include information for both dual and non-dualmembers.

Table 4: Foster Children and Adopted Children Population CriteriaPopulation Group Detailed Population Group Program Aid Code/Eligibility Code

Foster Children andAdopted Children

N/A HSFCY, HSFNN, IASCN, IASCY, MFCNN

2 NC Basic Medicaid Income Eligibility Chart, March 2017,https://files.nc.gov/ncdma/documents/files/BASIC_MEDICAID_INCOME_ELIGIBLITY_CHART_2017_03_10.pdf3 North Carolina DHHS On-line Manual, April 2014,https://www2.ncdhhs.gov/info/olm/manuals/dma/fcm/man/MA3255-05.htm

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2.2.3 BH I/DD Tailored Plan (Non-Dual and Dual Eligibles)The data was further segmented for beneficiaries eligible to participate in the BH I/DD Tailored Plan as currentlyproposed by DHHS. The criteria utilized to summarize beneficiaries in the BH I/DD Tailored Plan is outlinedbelow. To qualify under a clinical category, the beneficiary only needed to meet the criteria once during a StateFiscal Year (July 1 through June 30). The CAP/C, CAP/DA, Nursing Facility Level of Care (NFLOC) and FosterChildren and Adopted Children population groups have not been included in the BH I/DD Tailored Plansummaries.

The clinical condition criteria are applied as a hierarchy such that beneficiaries only fall within one of the clinicalcondition categories in a given year. The following proposed populations would default into the BH I/DD TailoredPlan. Summaries for these specific populations are outlined in Section 6.

1. I/DD Default — This group will be defaulted into the BH I/DD Tailored Plan. In order to identify qualifyingbeneficiaries, Mercer and the State discussed an approach to use the available claims and eligibilityinformation to identify the I/DD default group; specifically, beneficiaries were assigned if they met at leastone of the following criteria:

a. Innovations — Special Coverage Code of CM, C2 or IN (Innovations eligibility indicators).b. Intermediate Care Facility for Individuals with Intellectual and Developmental Disabilities (ICF/IID) —

Fee-for-service (FFS) data claim type Q (Mental Health) and FFS category of service (COS) 0021 (LTC-ICF MRC, SO) or 0047 (LTC-ICF MRC, NSO). Encounter data claim experience with revenue codes 100(room and board, all-inclusive plus ancillary) or 183 (therapeutic leave) used by the LocalManagement Entity/Managed Care Organizations (LME/MCOs) to reimburse for ICF/IID services.

c. B3 — One or more claims falling under the B3 COS.d. Diagnosis — List of I/DD diagnosis codes (all diagnosis positions) supplied by the State.e. Transition to Community Living Initiative (TCLI) — Beneficiaries who were included on the TCLI

roster provided by the State.2. Serious and Persistent Mental Illness (SPMI)/Serious Emotional Disturbance (SED) Beneficiaries with

Enhanced BH Utilization — This group will be defaulted into the BH I/DD Tailored Plan; beneficiaries neededto have accessed an enhanced BH service and were identified based on a list of diagnosis codes (primarydiagnosis position) supplied by the State. SPMI is defined as being for individuals ages 18 +, while SED isdefined as being for individuals ages 0 to 17.99.

3. Substance Use Disorder (SUD) Beneficiaries with Enhanced BH Utilization — This group will be defaulted intothe BH I/DD Tailored Plan; beneficiaries needed to have accessed an enhanced BH service and wereidentified based on a list of diagnosis codes (primary diagnosis position) supplied by the State along withbeneficiaries with a qualifying SUD drug claim.

Note that information for these populations (included in Section 6) was summarized by child (<21) and adult(21+). Information on the specific I/DD, SPMI, SED, and SUD diagnosis codes used to identify members as eligiblefor the BH I/DD Tailored Plan default population are found in Appendix A.

DHHS is proposing to include other Medicaid and NC Health Choice beneficiaries, such as those on theInnovations waiver waitlist, those enrolled on the TBI waiver, and those with historical utilization of State-funded mental health services in BH I/DD Tailored Plans, however, these beneficiaries are not included as part ofthis population for purposes of this report.

2.2.4 Non-Dual LTSS PopulationTable 5 outlines the three LTSS population breakouts for non-dual beneficiaries. Note that these breakoutsinclude specific summaries for beneficiaries enrolled in the CAP/C and CAP/DA 1915(c) Home and CommunityBased Services waiver, along with information for beneficiaries with a long-term nursing home stay.

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Table 5: Non-Dual LTSS Population CriteriaPopulation Group Detailed Population Group Program Aid Code/Eligibility Code

LTSS — CAP/C N/A Setting of Care codes (HC, IC or SC)

LTSS — CAP/DA N/A Setting of Care codes (CI, CS, ID or SD)

LTSS — NFLOC N/A Identify 3 months of consecutive nursing home utilization;mark member as being NF from first month of 3 monthconsecutive utilization forward

2.2.5 Dual EligiblesA beneficiary was identified as dual-eligible if either their eligibility fields “MA_STATUS” or “MB_STATUS” had avalue of “MA” or “MB” respectively. Dual eligible beneficiaries not identified as eligible for the BH I/DD TailoredPlan were summarized into the following population groupings:· LTSS Population: CAP/C, CAP/DA and NFLOC· Non-LTSS Population: ABD, TANF and Other Related Children/Adults, NC Health Choice, M-CHIP, and Foster

Children and Adopted Children

Note that information for dual eligibles includes Medicaid only and Medicaid crossover cost and utilization, anddoes not include costs and utilization paid by Medicare.

2.2.6 Permanently ExcludedThe following populations are considered permanently excluded for purposes of managed care and will not bethe responsibility of the Prepaid Health Plans (PHPs). Note that an individual’s status in one of the groupsoutlined in Table 6 was assumed to supersede categorization into one of the covered population groupings. Forexample, an individual who is in the Health Insurance Premium Program is reported as such regardless of othereligibility categories.

Table 6: Permanently Excluded Population CriteriaPopulation Group Detailed Population Group Program Aid Code/Eligibility Code

Medically Needy N/A Fourth digit of program category code of “M”

Family Planning N/A MAFDN

Other Partial Duals MQBBN, MQBEN, MQBQN

Aliens (Emergency ServicesOnly)

Eligibility codes with a fourth character of F, H, O, R or V

Refugees MRFMN, MRFNN, RRFCN

Health Insurance PremiumProgram

Beneficiary roster provided by State

Inmates Living Arrangement Code 16

Note as a step in the data summarization process, Mercer limited the data to records with a matchingMedicaid or NC Health Choice eligibility segment in the member extract file on a monthly basis. This ensuresthat the base data underlying the capitation rates is for covered populations and services, as a result of thisstep the overall SFY 2015 and SFY 2016 costs decreased by 0.4% and 0.3%, respectively.

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3 COVERED SERVICESMercer has summarized the utilization and cost information from the historical fee-for-service (FFS) data andthe Local Management Entity/Managed Care Organization (LME/MCO) encounter data into the following majorservice categories. Appendix B contains detailed coding logic used to define each of the detailed categoriesnoted in Table 7 below.

The FFS data detailed category of service (COS) logic was developed to summarize expenses into the majorservice categories based on a combination of claim type and state-defined categories based on providertaxonomy. The encounter data detailed COS is based on the services defined and used for the development ofthe LME/MCO capitation rates. Appendix B shows how Mercer leveraged the existing FFS and encounter dataCOS logic to define service groupings for purposes of this report. The table below shows how the detailedservice categories were grouped for purposes of this report and the exhibits in Section 6.

Table 7: COS GroupingsCOS Grouping FFS Data Detailed COS Encounter Data Detailed COS

Inpatient — Physical Health (PH) Inpatient N/A

Inpatient — Behavioral Health (BH) N/A Inpatient

Outpatient Hospital Outpatient N/A

Emergency Room Emergency Room Emergency Room

Physician Physician N/A

Federally Qualified Health Center(FQHC)/Rural Health Clinic (RHC)

FQHCRHC

N/A

Other Clinic Free-standing ClinicsHealth Check — Health DepartmentFamily Planning

N/A

Other Practitioner ChiropracticPodiatry

N/A

Therapies Physical TherapySpeech TherapyOccupational Therapy

N/A

Prescribed Drugs Prescribed Drugs N/A

Enhanced Mental Health (MH) MH services for non-LME/MCOpopulation (Ages 0–3 and NC HealthChoice)

Assertive Community Treatment (ACT)BH Long Term ResidentialCommunity SupportCrisis ServicesIntensive In Home Services (IIHS)Multisystemic Therapy (MST)Outpatient (including psychotherapy andalcohol/drug services)Partial Hospitalization/Day TreatmentPsychiatric Residential Treatment Facility(PRTF)Psych Rehab

B3 Services N/A 1915(b)(3) Services

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COS Grouping FFS Data Detailed COS Encounter Data Detailed COS

Long Term Services and Supports(LTSS) — Intermediate Care Facilityfor Individuals with Intellectual andDevelopmental Disabilities (ICF/IID)and Nursing Home

ICF/IIDNursing Home

ICF/IID

LTSS — State Plan Home andCommunity Based Services (HCBS)

Home HealthHospicePersonal Care

N/A

LTSS — HCBS Waiver Services Community Alternatives Program forChildren (CAP/C) Waiver ServicesCommunity Alternatives Program forDisabled Adults (CAP/DA) Waiver Services

Innovations Waiver Services

Durable Medical Equipment Durable Medical Equipment N/A

Lab and X-Ray Lab and X-Ray N/A

Optical Optical N/A

Limited Dental Services Into the Mouth of Babes program N/A

Transportation AmbulanceNon-Emergency Medical Transportation(NEMT)

N/A

Case Management Human Immunodeficiency Virus (HIV)Case Management

N/A

Patient-Centered Medical Home(PCMH) Payments

PCMH Payments N/A

Note 1: NEMT costs are not captured in the historical FFS claims experience. An adjustment was included (noted in section 4) to build costsinto the transportation line to account for historical NEMT expenditures paid outside of the claims system.Note 2: Costs associated with oral/maxillofacial surgery and adjunctive general dental services will be covered by PHPs when billed as amedical or professional claim; based on the COS mapping logic these costs are captured in the above medical/professional service linesand thus not captured under the ‘Limited Dental Services’ COS.

The following detailed FFS categories of service are excluded:· Children’s Developmental Services Agencies (CDSA)· All other dental services· Local Education Agency (LEA)· Program for All-Inclusive Care for the Elderly (PACE) Capitation· Eyeglasses subsidized by the NC Department of Corrections, and associated with Nash Correctional

Institution, are also an excluded service. However, the costs summarized under the Optical COS inSection 6 have not been adjusted to remove these costs (approximately $3.7M in SFY 2016).

Note that to support the population profile data summarization process, cost and utilization information forLME/MCO and eviCore (previously MedSolutions) capitation payments for lab and radiology services wereremoved in order to not duplicate cost and utilization reflected in both the FFS data and the LME/MCOencounters.

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4 DATA ADJUSTMENTSThis section lists the adjustments Mercer made to the data sources summarized in this report. Theseadjustments are reflected in the exhibits shown in Section 6.

Completion Factors4.1The summarized data include claims for dates of service for state fiscal year (SFY) 2015 and SFY 2016. Mercerdeveloped completion factors to estimate incurred-but-not-reported (IBNR) claims (those claims not yetadjudicated). The fee-for-service (FFS) data reflects payments through June 2017, and the Local ManagementEntity/Managed Care Organization (LME/MCO) encounter data reflects payments through at least August 2016.The following factors are applied to both dollars and utilization. Given the varying amount of claims runout, thefactors were developed separately for the FFS claims reported through NC Tracks and the LME/MCO encounterdata for Behavioral Health (BH) services.

Table 8: Completion Factors

Category of Service (COS)

FFS Data Factors Encounter Data Factors

SFY 2015 SFY 2016 SFY 2015 SFY 2016

Inpatient — Physical Health (PH) 1.0001 1.0050 N/A N/A

Inpatient — BH (LME/MCO) N/A N/A 1.0025 1.0364

Outpatient Hospital 1.0000 1.0006 N/A N/A

Emergency Room 1.0000 1.0003 1.0004 1.0180

Physician 1.0000 1.0014 N/A N/A

Federally Qualified Health Center (FQHC)/RuralHealth Clinic (RHC)

1.0000 1.0015 N/A N/A

Other Clinic 1.0000 1.0014 N/A N/A

Other Practitioner 1.0000 1.0014 N/A N/A

Therapies 1.0000 1.0015 N/A N/A

Prescribed Drugs 1.0000 1.0000 N/A N/A

Enhanced BH 1.0000 1.0001 1.0002 1.0080

B3 Services N/A N/A 1.0000 1.0036

Long Term Services and Supports (LTSS) —Intermediate Care Facility for Individuals withIntellectual and Developmental Disabilities (ICF/IID)and Nursing Home

1.0000 1.0006 1.0001 1.0095

LTSS — State Plan Home and Community BasedServices (HCBS)

1.0000 1.0003 N/A N/A

LTSS — HCBS Waiver Services 1.0000 1.0003 1.0000 1.0030

Durable Medical Equipment 1.0000 1.0004 N/A N/A

Lab and X-Ray 1.0000 1.0004 N/A N/A

Optical 1.0000 1.0004 N/A N/A

Limited Dental Services 1.0000 1.0004 N/A N/A

Transportation 1.0000 1.0004 N/A N/A

Case Management 1.0000 1.0001 N/A N/A

Patient-Centered Medical Home (PCMH) Payments 1.0000 1.0001 N/A N/A

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Category of Service (COS)

FFS Data Factors Encounter Data Factors

SFY 2015 SFY 2016 SFY 2015 SFY 2016

Capitation – Program for All-Inclusive Care for theElderly (PACE)

1.0000 1.0001 N/A N/A

Dental 1.0000 1.0001 N/A N/A

Local Education Agency (LEA) 1.0000 1.0001 N/A N/A

Children’s Developmental Services Agencies (CDSA) 1.0000 1.0001 N/A N/A

Total 1.0000 1.0007 1.0002 1.0083

Graduate Medical Expense (GME) Adjustment4.2GME factors are included directly in the calculation of FFS and LME/MCO payment rates for the hospitals eligiblefor GME; the State does not make supplemental payments to hospitals for GME. The State has chosen toexclude the GME portion of the Inpatient claims in the data and therefore from the future prepaid health plan(PHP) capitation payments. This is allowable per the Centers for Medicare and Medicaid Services (CMS). TheState will reimburse hospitals eligible for GME directly and thus PHPs will not be expected to reimburse the GMEhospitals at an enhanced rate. Mercer has applied a downward adjustment to the FFS and LME/MCO encounterdata to remove these payments from the summarized data. To calculate this adjustment, Mercer relied on theGME payment information provided by the State that included GME amounts by hospital. The table belowillustrates the adjustment applied to each base year.

Table 9: GME Adjustment Impact

Time Period COS

FFS Data Impact Encounter Data Impact

Dollar Amount Percentage Impact Dollar Amount Percentage Impact

SFY 2015 Inpatient ($99,454,830) -10.2% ($6,017,483) -5.5%

SFY 2016 Inpatient ($97,152,812) -10.3% ($5,925,214) -5.2%

Cost Settlements4.3Under FFS, the State makes cost settlements to certain provider types as part of the overall providerreimbursement. Generally under managed care, the CMS does not allow provider payments to be made by theState outside of the capitation payment to PHPs aside from a few exceptions (e.g., wrap payments forFQHC/RHC provider types may continue to be made outside of the capitation payment under managed care).However, the State is seeking approval from the CMS, through the 1115 waiver, to maintain cost settlements forcertain provider types: Public Ambulance, Local Health Departments (LHDs) and State Owned and OperatedSkilled Nursing Facilities (SNFs). In order to represent the full level of current provider reimbursement, Mercerhas included information in Table 10 on the amount of cost settlements for the SFY 2015 and SFY 2016 baseyears. Note that the summaries in Section 6 have not been adjusted to reflect these cost settlement amounts.For rate-setting, Mercer will include consideration for the settlements in the capitation rates for provider typeswithout a CMS-approved wraparound process.

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Table 10: Cost Settlement Amounts

Provider TypeSFY 2015 Settlement

AmountSFY 2016 Settlement

AmountProposed Payment Consideration

Acute Care Hospitals ($76,937,880) ($53,671,340) PHP Rates

Ambulance $58,665,724 $60,800,909 State Wrap

FQHC/RHC4 $8,096,447 $14,102,887 State Wrap

LHDs $67,825,066 Not Available State Wrap

State Owned and Operated SNFs ($3,633,088) ($6,123,526) State Wrap

CDSA $32,266,238 $32,924,391 State (non-covered service)

LEA $71,304,953 $65,797,936 State (non-covered service)Note 1: Cost settlements are not applied to dual-eligible beneficiaries.

It is important to note that for rate development Mercer will evaluate all PHP provider reimbursementrequirements in the PHP contract. For certain cost settled provider types, most notably FQHC/RHCs, the analysismay result in an adjustment to the historical FFS reimbursement rates if the current FQHC/RHC providerpayments (before settlements) are different than the average payment rate for comparable provider types.

Hospital Supplemental Payments4.4Hospital supplemental reimbursement considerations will need to be included as a part of capitation ratedevelopment to reflect future provider reimbursement under managed care. In total for Federal Fiscal Year (FFY)2017, hospital supplemental payments are approximately $1.5 billion for Inpatient Hospital services and $325million for Outpatient Hospital services (including Emergency Room services). It is important to note that thisfigure is in total across all Medicaid populations. However, no adjustments have been made to the populationprofile data summaries with regards to hospital supplemental payments or settlements made to Critical AccessHospitals and Vidant Medical Center. The table below provides a comparison of the supplemental payments andtotal claims costs. Supplemental payments do not include Disproportionate Share Hospital (DSH) payments.

Table 11: Supplemental PaymentsService FFY 2017 Supplemental Payment Service Claims Costs

Inpatient Hospital $1.5 Billion $925 Million

Outpatient Hospital (including Emergency Room services) $325 Million $825 Million

Intermediate Care Facilities for Individuals with Intellectual and Developmental4.5Disabilities (ICF/IID)

Mercer incorporated an adjustment to include dollars for ICF/IID settlements that were not part of the claimscategorized under the 1915(b)/(c) waiver for children aged 0–3. Based on historical cost settlements for ICF/IIDservices and per discussions with the State, Mercer added approximately $200,000 per base period to the FFSdata for the ICF/IID service category for the population ages 0–3.

Non-Emergency Medical Transportation (NEMT) Adjustment4.6Historically, payments for NEMT providers were processed outside of NC Tracks; the State supplied informationon NEMT payment costs for the SFY 2015 and SFY 2016 time periods. Effective October 2017, the State began to

4 The NC Medicaid State Plan requires FQHCs and RHCs to follow Medicare cost reporting principles. Medicare significantlychanged their reimbursement methodology for FQHCs in 2014-2015. The first full year in which this change was recognizedin NC was 2016.

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process NEMT payments for pilot counties through NC Tracks. Mercer leveraged the SFY 2015 and SFY 2016NEMT payments provided by the State and the distribution of NEMT costs after October 2017 in the FFS data toallocate the historical NEMT costs across the population groupings. However, since the SFY 2017 data only hadinformation for piloted counties, Mercer leveraged the distribution of total costs from the base time periods toallocate the NEMT costs by region. Additionally, information was not available on Behavioral Health (BH) andIntellectual/Developmental Disability (I/DD) Tailored Plans for the SFY 2017 time period, so NEMT costs weresimilarly allocated to BH I/DD Tailored Plan populations based on total costs from the base time periods. Thetable below illustrates the allocated NEMT costs by population for the base time periods.

Table 12: NEMT Adjustment AmountPopulation SFY 2015 Dollars SFY 2016 Dollars

Aged, Blind and Disabled (ABD) $10,733,931 $11,605,368

Temporary Assistance for Needy Families (TANF) and Other RelatedChildren/Adults

$6,539,992 $7,085,578

NC Health Choice $0 $0

Medicaid-Children's Health Insurance Program (M-CHIP) $123,269 $133,910

Foster Care and Adopted Children $452,666 $493,027

BH I/DD Tailored Plan $12,553,155 $14,239,060

Long Term Services and Supports (LTSS) — Community Alternatives Programfor Children (CAP/C)

$225,586 $245,700

LTSS — Community Alternatives Program for Disabled Adults (CAP/DA) $961,135 $1,046,834

LTSS — Nursing Facility Level of Care (NFLOC) $42,258 $46,026

Dual Eligibles $21,817,229 $23,319,460

Permanently Excluded $,471,733 $513,795

Total $53,920,954 $58,728,758

LME/MCO Adjustments4.7The following represents adjustments specific to the LME/MCO encounter data.

4.7.1 Patient Liability AdjustmentIn the North Carolina BH managed care program operated by the LME/MCOs under concurrent 1915(b)/(c)waiver authority, certain beneficiaries receiving services in ICF/IIDs have patient liability responsibilities throughpost-eligibility treatment of income to contribute to the reimbursement of their services. In the Medicaid FFSprogram, the ICF/IID facilities collect these patient liability payments directly from the beneficiary and submit aFFS claim to Medicaid identifying the collected patient liability and the remaining expense eligible for Medicaidreimbursement.

Under the LME/MCO BH managed care program, the State has been following a similar transactional process,where the ICF/IID continues to collect the patient liability directly from the beneficiary and submits a claim tothe LME/MCO for the balance of the charges. Mercer has reviewed the patient liability required for theimpacted beneficiaries each month from the statewide eligibility file and compared to the patient liabilitycollected and documented by the LME/MCO. Based on this review of ICF/IID encounter claims, an adjustmentwas made to account for the difference between the required amount and reported amount of patient liabilityobserved in the documentation provided by the LME/MCO. The adjustment ensures the base data reflectsclaims expenses that are the responsibility of the LME/MCOs.

Table 13: Patient Liability Adjustment

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Time Period COS Adjustment Amount Adjustment Impact

SFY 2015 LTSS — ICF/IID and Nursing Home ($1,284,965) -0.2%

SFY 2016 LTSS — ICF/IID and Nursing Home $11,458 0.0%

As mentioned, this adjustment is only applicable to the LME/MCO encounter data since there is a process inplace to account for patient liability during FFS claims processing.

4.7.2 Payments Made Outside of the Claims SystemLME/MCOs have historically documented payments for services paid outside of the claims system that were nototherwise represented in the base data. LME/MCOs provided Mercer with documentation of these payments byCOS and date of service. Mercer used this information to build in an adjustment to the historical experience toensure that the data was fully representative of all BH service costs. This adjustment increased the SFY 2015 andSFY 2016 encounter data by 0.5% and 0.4%, respectively.

Pharmacy Rebates4.8To support PHP capitation rate development, the base data should reflect costs and utilization that are theresponsibility of the PHPs. Since the State will retain the ability to collect supplemental rebates, Mercer did notadjust the pharmacy claims experience for State pharmacy rebates. However, it is important to note that undermanaged care the PHPs are expected to be able to receive a nominal level of rebates. As a part of the capitationrate setting process, Mercer will evaluate the expected level of PHP rebates and if necessary, make anadjustment to reflect these PHP rebates under managed care.

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5 BASE DATA SUMMARIZATION NEXT STEPSInformation contained in this report includes relevant historical cost and utilization information for coveredpopulations and services included in the proposed managed care program design for purposes of providingtransparency into the current program costs and utilization by covered population cohorts for potential PrepaidHealth Plans (PHPs) and other interested stakeholders. While cost and utilization information summarized inSection 6 of this report reflect adjustments outlined in Section 4, additional adjustments to the base experiencewill be necessary to fully reflect PHP payment responsibility. Below is a list of known adjustments andprogrammatic changes that may be applied in summarization of the final base experience in support ofcapitation rate development. These are currently not reflected in the Population Profile exhibits in Section 6.

1. Refinements to the final covered population groups, including but not limited to the following:a. Tribal membersb. BH I/DD Tailored Plan population (potential refinements of the definition)

2. Refinements to the final covered services, including but not limited to the following:a. Consideration for Nash Correctional Institution carve out for Optical services

3. Third Party Liability (TPL) — The claims data reflects the reduction for TPL if reported on the claimsubmitted by the provider; an additional adjustment may be applied to reflect additional TPL recoveryamounts not reflected in the claims data.

4. Cost Settlements — As noted in section 4.3, additional analysis and consideration will need to be madeto the capitation rates to reflect PHP reimbursement requirements outlined in the PHP contract.Additionally, provider reimbursement levels reflected in the base data will also be influenced by Statenegotiations with the Centers for Medicare and Medicaid Services (CMS) regarding which provider typesthe State will continue to cost settle; as a reminder, the State is currently negotiating the ability tomaintain cost settlements for the following provider types (along with those for Federally QualifiedHealth Centers (FQHC) and Rural Health Clinics (RHC)): Ambulance, Local Health Departments (LHDs)and State Owned and Operated Skilled Nursing Facilities.

5. Supplemental Payments — Hospital supplemental reimbursement considerations will need to beincluded as a part of capitation rate development to reflect future provider reimbursement undermanaged care. As mentioned, no adjustments have been made to the population profile datasummaries with regards to hospital supplemental payments or settlements made to Critical AccessHospitals and Vidant Medical Center.

6. Retroactive eligibility — The retroactive eligibility period reflects a potential period of Medicaideligibility that is identified during Medicaid eligibility application that provides retrospective coverage ofclaims prior to the prospective date of Medicaid coverage. In order to ensure the data summarizationreflects only cost/utilization that will be the responsibility of the prepaid health plans (PHPs), anadjustment will be applied to remove the cost and utilization associated with the retroactive eligibilityperiod.

7. Application/enrollment lag period — The application/enrollment lag period represents the timebetween initial application for Medicaid eligibility and PHP enrollment. Based on conversations with theState, the application lag period (time between initial application and eligibility determination) maydecrease compared to the historical experience. Mercer will evaluate the anticipatedapplication/enrollment lag period and calculate how it may affect the average per member per month(PMPM) represented in the historical data. Cost and utilization associated with theapplication/enrollment lag period will not be included in the final base data.

After finalizing the base data, Mercer will work to incorporate additional prospective adjustments as a part ofthe capitation rate development process.

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6 POPULATION PROFILE DATA EXHIBITS OVERVIEWMercer summarized the underlying experience based on a number of criteria. The following section presents anorientation of the information contained in each exhibit. The exhibits included in Section 7 and Section 8 containdata on detailed population groups and regions, respectively. Each of the sections is organized by State FiscalYear (SFY) and by major Program Type (defined in Sections 2.2.1 through 2.2.5).

At the top of each page, the base experience was summarized based on the following criteria:· Time Period: SFY 2015 or SFY 2016· Region: Regional breakouts based on Section 1.1.2 of the narrative· Plan/Program: Selection based on plan/program type outlined in Section 2 of the narrative:

o Standard Plano Foster Children and Adopted Childreno Behavioral Health (BH) and Intellectual/Developmental Disability (I/DD) Tailored Plano Non-Dual Long Term Services and Supports (LTSS)o Dual Eligibles (excluding those eligible for BH I/DD Tailored Plan)

· Population Grouping: Specific population groups as defined in Section 2 of the narrative· Age Grouping: Specific age groups as defined in Section 2 of the narrative

Below the population criteria is information on the following metrics associated with the population selections:· Member Months (MMs): Reflect a count of monthly eligibles for the historical time period· Average Monthly Members: MMs divided by 12.· Category of Service: As described in Section 3, each of the covered services is listed· Paid Claims: Amount paid for each service line item based on the paid amount field included in both the fee-

for-service provided by the State and the encounter data provided by the Local ManagementEntity/Managed Care Organizations; these amounts are based on date of service and reflect the applicabledata adjustments outlined in Section 4

· Utilization: Utilization for each service line item. This represents the number of visits, days, services orscripts for each category as reported in the data after application of adjustments outlined in Section 4; seebelow for the unit types used to define utilization for the various service categories:

o Days: Inpatient, Intermediate Care Facility for Individuals with Intellectual and DevelopmentalDisabilities (ICF/IID), Nursing Home, Psychiatric Residential Treatment Facility (PRTF)

o Visits: Emergency Room, Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC), OtherClinic, Other Practitioner, Outpatient Hospital, Physician, Therapies

o Scripts: Pharmacyo Count of procedures or units: service categories not listed above

· Utilization per 1,000: Annual utilization for each service divided by total MMs multiplied by 12,000· Unit Cost: Average cost of each service line item; paid claims divided by the utilization of services delivered· Per Member Per Month (PMPM): Paid claims divided by total MMs

Note that for reference, an Excel file (called Population Profile Exhibits) has been provided to accompany thisdocument that contains all data exhibits included in this report.

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7 POPULATION GROUP EXHIBITSThe exhibits included in Section 7 summarize the cost and utilization data for each Program Type by the variousPopulation Groups. These exhibits are provided for the SFY 2015 time period in Section 7.1, and the SFY 2016time period is included in Section 7.2. See the grid below highlighting the information available in each of thedetailed exhibit sections.

SFY 2015Exhibit

SFY 2016Exhibit

Description

7.1.1 7.2.1 Exhibits summarize information for the Standard Plan (Non-Duals) Program Type for the followingdetailed Population Groups and Age Groups:

· Aged, Blind, Disabled (ABD): newborn, child, adult· Temporary Assistance for Needy Families (TANF) and Other Related Children/Adults:

newborn, child, adult· NC Health Choice: all ages· Medicaid-Children’s Health Insurance Program (M-CHIP): all ages· Maternity: all ages

7.1.2 7.2.2 Exhibit summarizes information for the Foster Children and Adopted Children Population Grouping,for all ages.

7.1.3 7.2.3 Exhibits summarize information for the Behavioral Health (BH) Intellectual/Developmental Disability(I/DD) Tailored Plan Program Type for the following detailed Population Groups and Age Groups:

· I/DD Non-Dual: child, adult· I/DD Dual Eligibles: all ages· Serious and Persistent Mental Illness (SPMI)/Serious Emotional Disturbance (SED) Non-

Dual: child, adult· SPMI/SED Dual Eligibles: all ages· Substance Use Disorder (SUD) Non-Dual: child, adult· SUD Dual Eligibles: all ages

7.1.4 7.2.4 Exhibits summarize information for the Non-Dual Long Term Services and Supports (LTSS) ProgramType for the following detailed Population Groups and Age Groups:

· Community Alternatives for Children (CAP/C) waiver beneficiaries: all ages· Community Alternatives for Disabled Adults (CAP/DA) waiver beneficiaries: all ages· Nursing Facility Level of Care (NFLOC): all ages

7.1.5 7.2.5 Exhibits summarize information for Dual Eligibles for the following detailed Population Groups andAge Groups:

· Non-LTSS Population including ABD, TANF and Other Related Children/Adults, NC HealthChoice, M-CHIP, and Foster Children and Adopted Children: all ages

· LTSS Population including CAP/C, CAP/DA, and NFLOC: all ages

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SFY 2015 Population Group Exhibits7.1Cost and utilization information for the July 1, 2014 through June 30, 2015 (SFY 2015) time period is illustrated inSection 7.1.

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7.1.1 SFY 2015 Standard Plan (Non-Duals)

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Exhibit 1Time Period/Region Selections:Time Period:

Region:

Population Selections:Program Type: Invalid

Population Group:

Dual/Non-Dual:

Age:

Member Months:Average Member Months per Month:

Category of Service Paid Claims UtilizationUtilizationPer 1,000

Unit Cost PMPM

Inpatient — PH 13,843,981$ 22,866 29,858 605.43$ 1,506.42$Inpatient — BH (LME/MCO) -$ - - -$ -$Outpatient Hospital 464,333$ 1,833 2,393 253.32$ 50.53$Emergency Room 239,775$ 762 995 314.67$ 26.09$Physician 8,358,202$ 28,195 36,817 296.44$ 909.49$FQHC/RHC 26,483$ 233 304 113.66$ 2.88$Other Clinic 198,014$ 1,753 2,289 112.95$ 21.55$Other Practitioner 136$ 4 5 34.11$ 0.01$Therapies 128,231$ 1,026 1,340 124.98$ 13.95$Prescribed Drugs 1,910,672$ 4,874 6,364 392.01$ 207.91$Enhanced BH 22,478$ 2,005 2,618 11.21$ 2.45$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 527,976$ 40,947 53,467 12.89$ 57.45$LTSS – HCBS Waiver Services 141$ 10 13 14.14$ 0.02$Durable Medical Equipment 397,894$ 127,485 166,466 3.12$ 43.30$Lab and X-Ray 200,478$ 9,952 12,995 20.14$ 21.81$Optical 978$ 47 61 20.80$ 0.11$Limited Dental Services 9,480$ 382 499 24.82$ 1.03$Transportation 62,181$ 5,922 7,732 10.50$ 6.77$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 52,782$ 15,759 20,578 3.35$ 5.74$Subtotal (Covered Services) 26,444,214$ 264,055 2,877.50$

Capitation — PACE -$ - - -$ -$Dental 746$ 27 35 27.63$ 0.08$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) 153,953$ 6,086 7,947 25.30$ 16.75$Subtotal (Excluded Services) 154,699$ 6,113 16.83$Total (All) 26,598,913$ 270,168 2,894.33$

Category of Service NotesThe service categories listed below include the following detailed service categories:Other ClinicOther PractitionerTherapiesEnhanced BH

LTSS — State Plan Home and Community Based Services (HCBS)LTSS – HCBS Waiver ServicesTransportation

SFY 2015

Statewide

Standard Plan

Aged, Blind, Disabled

Non-Duals

Newborn (<1)

9,190766

Ambulance, Non-Emergent Medical Transportation (NEMT)

Free-standing Clinics, Health Check - Health Department, Family PlanningChiropractic, PodiatryPhysical Therapy, Speech Therapy, Occupational TherapyBH services for non-LME/MCO population (Ages 0-3 and NC Health Choice), Assertive CommunityTreatment, BH Long-Term Residential, Community Support, Crisis Services, Intensive In HomeServices, Multisystemic Therapy, Partial Hospitalization/Day Treatment, Psychiatric ResidentialTreatment Facility, Psych Rehab, Outpatient (including psychotherapy and alcohol/drug services)

Home Health, Hospice, Personal CareInnovations, CAP/C, and CAP/DA waiver services

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Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 20,804,186$ 17,358 469 1,198.55$ 46.87$Inpatient — BH (LME/MCO) 1,773,762$ 2,602 70 681.61$ 4.00$Outpatient Hospital 18,894,731$ 41,031 1,109 460.50$ 42.57$Emergency Room 10,235,239$ 28,646 775 357.30$ 23.06$Physician 16,740,544$ 164,700 4,453 101.64$ 37.72$FQHC/RHC 816,797$ 7,807 211 104.62$ 1.84$Other Clinic 2,603,330$ 20,364 551 127.84$ 5.87$Other Practitioner 65,227$ 992 27 65.75$ 0.15$Therapies 9,392,812$ 80,763 2,184 116.30$ 21.16$Prescribed Drugs 91,580,793$ 419,126 11,332 218.50$ 206.34$Enhanced BH 9,608,993$ 194,125 5,249 49.50$ 21.65$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 9,360,134$ 1,667,703 45,090 5.61$ 21.09$LTSS – HCBS Waiver Services 4,267$ 318 9 13.42$ 0.01$Durable Medical Equipment 8,120,608$ 3,865,534 104,513 2.10$ 18.30$Lab and X-Ray 799,424$ 47,409 1,282 16.86$ 1.80$Optical 824,621$ 42,333 1,145 19.48$ 1.86$Limited Dental Services 44,610$ 1,779 48 25.08$ 0.10$Transportation 1,173,780$ 58,918 1,593 19.92$ 2.64$Case Management 1,866$ 144 4 12.96$ 0.00$Patient-Centered Medical Home (PCMH) Payments 6,739,496$ 1,204,350 32,562 5.60$ 15.18$Subtotal (Covered Services) 209,585,222$ 7,866,001 472.21$

Capitation — PACE 42,384$ 89 2 476.23$ 0.10$Dental 7,536,826$ 163,802 4,429 46.01$ 16.98$Local Education Agency (LEA) 2,758,803$ 81,256 2,197 33.95$ 6.22$Children’s Developmental Services Agencies (CDSA) 319,200$ 13,555 366 23.55$ 0.72$Subtotal (Excluded Services) 10,657,213$ 258,702 24.01$Total (All) 220,242,435$ 8,124,703 496.23$



SFY 2015

Statewide

Standard Plan


Non-Duals

Child (1-20)

443,83536,986




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Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 232,693,730$ 241,973 2,385 961.65$ 191.10$Inpatient — BH (LME/MCO) 9,237,824$ 13,958 138 661.81$ 7.59$Outpatient Hospital 144,225,703$ 289,109 2,849 498.86$ 118.44$Emergency Room 95,886,630$ 179,310 1,767 534.75$ 78.75$Physician 161,171,556$ 1,098,019 10,821 146.78$ 132.36$FQHC/RHC 8,605,498$ 80,264 791 107.22$ 7.07$Other Clinic 13,650,068$ 27,099 267 503.72$ 11.21$Other Practitioner 1,399,572$ 18,036 178 77.60$ 1.15$Therapies 459$ 7 0 65.54$ 0.00$Prescribed Drugs 469,917,912$ 4,082,259 40,230 115.11$ 385.91$Enhanced BH 18,658,280$ 642,686 6,334 29.03$ 15.32$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 1,982,306$ 10,705 106 185.17$ 1.63$LTSS – State Plan Home and Community Based Services (HCBS) 99,618,405$ 21,269,958 209,612 4.68$ 81.81$LTSS – HCBS Waiver Services 83,026$ 24,361 240 3.41$ 0.07$Durable Medical Equipment 46,073,291$ 15,419,629 151,958 2.99$ 37.84$Lab and X-Ray 15,708,994$ 904,852 8,917 17.36$ 12.90$Optical 1,212,780$ 19,004 187 63.82$ 1.00$Limited Dental Services 1$ 2 0 0.31$ 0.00$Transportation 18,252,877$ 639,282 6,300 28.55$ 14.99$Case Management 515,313$ 39,882 393 12.92$ 0.42$Patient-Centered Medical Home (PCMH) Payments 15,310,894$ 1,823,202 17,967 8.40$ 12.57$Subtotal (Covered Services) 1,354,205,118$ 46,823,598 1,112.12$

Capitation — PACE 1,884,886$ 1,063 10 1,773.18$ 1.55$Dental 20,358,723$ 288,001 2,838 70.69$ 16.72$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 22,243,610$ 289,064 18.27$Total (All) 1,376,448,727$ 47,112,662 1,130.39$



SFY 2015

Statewide

Standard Plan


Non-Duals

Adult (21+)

1,217,678101,473




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Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 136,685,764$ 248,343 3,346 550.39$ 153.49$Inpatient — BH (LME/MCO) -$ - - -$ -$Outpatient Hospital 9,755,706$ 59,989 808 162.62$ 10.95$Emergency Room 19,979,714$ 79,123 1,066 252.52$ 22.44$Physician 64,736,832$ 686,229 9,247 94.34$ 72.69$FQHC/RHC 4,253,369$ 39,326 530 108.16$ 4.78$Other Clinic 36,839,098$ 329,631 4,442 111.76$ 41.37$Other Practitioner 21,654$ 469 6 46.17$ 0.02$Therapies 538,200$ 5,385 73 99.94$ 0.60$Prescribed Drugs 11,828,862$ 284,767 3,837 41.54$ 13.28$Enhanced BH 48,177$ 3,150 42 15.29$ 0.05$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 685,861$ 38,012 512 18.04$ 0.77$LTSS – HCBS Waiver Services 71$ 5 0 14.14$ 0.00$Durable Medical Equipment 4,349,434$ 728,715 9,819 5.97$ 4.88$Lab and X-Ray 11,450,507$ 570,952 7,694 20.06$ 12.86$Optical 30,796$ 819 11 37.60$ 0.03$Limited Dental Services 2,095,749$ 84,205 1,135 24.89$ 2.35$Transportation 1,061,699$ 90,511 1,220 11.73$ 1.19$Case Management 104$ 8 0 12.96$ 0.00$Patient-Centered Medical Home (PCMH) Payments 6,050,774$ 2,330,500 31,404 2.60$ 6.79$Subtotal (Covered Services) 310,412,372$ 5,580,140 348.57$

Capitation — PACE -$ - - -$ -$Dental 250,455$ 7,286 98 34.37$ 0.28$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) 405,042$ 14,672 198 27.61$ 0.45$Subtotal (Excluded Services) 655,497$ 21,958 0.74$Total (All) 311,067,870$ 5,602,098 349.30$



SFY 2015

Statewide

Standard Plan

TANF and Other Related Children/Adults

Non-Duals

Newborn (<1)

890,53774,211




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Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 49,197,780$ 41,223 47 1,193.46$ 4.71$Inpatient — BH (LME/MCO) 8,119,073$ 12,723 15 638.16$ 0.78$Outpatient Hospital 93,871,760$ 363,975 418 257.91$ 8.99$Emergency Room 152,484,945$ 506,870 582 300.84$ 14.60$Physician 211,907,884$ 2,747,249 3,156 77.13$ 20.28$FQHC/RHC 18,722,782$ 177,050 203 105.75$ 1.79$Other Clinic 69,802,034$ 610,558 701 114.32$ 6.68$Other Practitioner 1,364,726$ 16,733 19 81.56$ 0.13$Therapies 42,653,454$ 365,007 419 116.86$ 4.08$Prescribed Drugs 336,070,205$ 3,838,483 4,409 87.55$ 32.17$Enhanced BH 60,219,331$ 1,231,114 1,414 48.91$ 5.76$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 4,133$ 33 0 125.24$ 0.00$LTSS – State Plan Home and Community Based Services (HCBS) 2,138,318$ 340,457 391 6.28$ 0.20$LTSS – HCBS Waiver Services 5,830$ 187 0 31.17$ 0.00$Durable Medical Equipment 15,716,335$ 6,480,237 7,443 2.43$ 1.50$Lab and X-Ray 13,052,480$ 809,410 930 16.13$ 1.25$Optical 15,246,974$ 742,661 853 20.53$ 1.46$Limited Dental Services 4,290,557$ 172,208 198 24.91$ 0.41$Transportation 6,001,272$ 264,151 303 22.72$ 0.57$Case Management 829$ 64 0 12.96$ 0.00$Patient-Centered Medical Home (PCMH) Payments 71,355,073$ 29,604,690 34,004 2.41$ 6.83$Subtotal (Covered Services) 1,172,225,774$ 48,325,082 112.20$

Capitation — PACE 39,689$ 904 1 43.90$ 0.00$Dental 194,855,305$ 4,493,050 5,161 43.37$ 18.65$Local Education Agency (LEA) 7,409,844$ 232,581 267 31.86$ 0.71$Children’s Developmental Services Agencies (CDSA) 1,571,162$ 59,427 68 26.44$ 0.15$Subtotal (Excluded Services) 203,875,999$ 4,785,962 19.51$Total (All) 1,376,101,773$ 53,111,044 131.72$



SFY 2015

Statewide

Standard Plan


Non-Duals

Child (1-20)

10,447,456870,621




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Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 68,131,814$ 66,465 303 1,025.08$ 25.84$Inpatient — BH (LME/MCO) 4,903,325$ 7,723 35 634.91$ 1.86$Outpatient Hospital 112,957,307$ 371,254 1,690 304.26$ 42.85$Emergency Room 149,484,663$ 339,137 1,544 440.78$ 56.70$Physician 155,544,491$ 1,375,971 6,263 113.04$ 59.00$FQHC/RHC 10,031,010$ 93,570 426 107.20$ 3.81$Other Clinic 25,296,919$ 151,891 691 166.55$ 9.60$Other Practitioner 1,287,447$ 18,973 86 67.86$ 0.49$Therapies 149$ 5 0 29.79$ 0.00$Prescribed Drugs 242,763,995$ 3,136,015 14,275 77.41$ 92.09$Enhanced BH 20,317,895$ 503,799 2,293 40.33$ 7.71$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 264,439$ 1,878 9 140.80$ 0.10$LTSS – State Plan Home and Community Based Services (HCBS) 5,426,404$ 1,070,426 4,873 5.07$ 2.06$LTSS – HCBS Waiver Services 17,782$ 2,978 14 5.97$ 0.01$Durable Medical Equipment 13,772,126$ 5,994,204 27,286 2.30$ 5.22$Lab and X-Ray 38,348,861$ 1,950,129 8,877 19.66$ 14.55$Optical 1,033,552$ 15,345 70 67.35$ 0.39$Limited Dental Services 111$ 5 0 22.15$ 0.00$Transportation 8,209,340$ 236,443 1,076 34.72$ 3.11$Case Management 73,119$ 5,680 26 12.87$ 0.03$Patient-Centered Medical Home (PCMH) Payments 15,181,474$ 4,105,632 18,689 3.70$ 5.76$Subtotal (Covered Services) 873,046,222$ 19,447,522 331.18$

Capitation — PACE 85,829$ 701 3 122.44$ 0.03$Dental 51,171,277$ 788,060 3,587 64.93$ 19.41$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 51,257,105$ 788,761 19.44$Total (All) 924,303,327$ 20,236,283 350.62$



SFY 2015

Statewide

Standard Plan


Non-Duals

Adult (21+)

2,636,201219,683




27 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,551,154$ 3,826 46 1,189.41$ 4.58$Inpatient — BH (LME/MCO) 3,807$ 5 0 760.16$ 0.00$Outpatient Hospital 10,256,877$ 36,620 442 280.09$ 10.31$Emergency Room 9,805,346$ 27,603 333 355.22$ 9.86$Physician 25,383,639$ 285,324 3,442 88.96$ 25.52$FQHC/RHC 1,404,966$ 12,975 157 108.28$ 1.41$Other Clinic 3,309,381$ 26,952 325 122.79$ 3.33$Other Practitioner 223,483$ 3,426 41 65.23$ 0.22$Therapies 1,338,923$ 13,631 164 98.22$ 1.35$Prescribed Drugs 46,365,258$ 385,627 4,652 120.23$ 46.61$Enhanced BH 3,861,247$ 50,680 611 76.19$ 3.88$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 120,912$ 7,708 93 15.69$ 0.12$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 2,712,783$ 871,941 10,519 3.11$ 2.73$Lab and X-Ray 958,507$ 69,116 834 13.87$ 0.96$Optical 2,211,807$ 106,820 1,289 20.71$ 2.22$Limited Dental Services 409$ 5 0 81.78$ 0.00$Transportation 189,740$ 10,794 130 17.58$ 0.19$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 5,434,322$ 1,605,650 19,371 3.38$ 5.46$Subtotal (Covered Services) 118,132,561$ 3,518,705 118.77$

Capitation — PACE -$ - - -$ -$Dental 17,893,377$ 469,599 5,665 38.10$ 17.99$Local Education Agency (LEA) 781$ 16 0 48.84$ 0.00$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 17,894,159$ 469,615 17.99$Total (All) 136,026,720$ 3,988,320 136.76$



SFY 2015

Statewide

Standard Plan

NC Health Choice

Non-Duals

All Ages

994,65882,888




28 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 9,080,511$ 11,297 95 803.81$ 6.39$Inpatient — BH (LME/MCO) 873,771$ 1,469 12 594.70$ 0.62$Outpatient Hospital 13,589,524$ 50,280 425 270.28$ 9.57$Emergency Room 15,511,633$ 51,188 432 303.03$ 10.92$Physician 31,888,196$ 415,848 3,513 76.68$ 22.45$FQHC/RHC 2,220,298$ 21,159 179 104.94$ 1.56$Other Clinic 9,523,037$ 85,036 718 111.99$ 6.70$Other Practitioner 250,857$ 3,535 30 70.96$ 0.18$Therapies 6,052,601$ 54,528 461 111.00$ 4.26$Prescribed Drugs 46,581,651$ 518,870 4,384 89.78$ 32.80$Enhanced BH 5,728,915$ 121,874 1,030 47.01$ 4.03$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 506,119$ 59,095 499 8.56$ 0.36$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 2,321,556$ 806,876 6,817 2.88$ 1.63$Lab and X-Ray 1,576,343$ 102,806 869 15.33$ 1.11$Optical 2,241,383$ 107,740 910 20.80$ 1.58$Limited Dental Services 472,885$ 19,031 161 24.85$ 0.33$Transportation 461,082$ 24,874 210 18.54$ 0.32$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 9,718,571$ 4,001,258 33,804 2.43$ 6.84$Subtotal (Covered Services) 158,598,933$ 6,456,764 111.66$

Capitation — PACE 3,539$ 84 1 42.13$ 0.00$Dental 26,970,991$ 642,188 5,425 42.00$ 18.99$Local Education Agency (LEA) 1,054,972$ 32,716 276 32.25$ 0.74$Children’s Developmental Services Agencies (CDSA) 194,328$ 7,467 63 26.03$ 0.14$Subtotal (Excluded Services) 28,223,830$ 682,455 19.87$Total (All) 186,822,763$ 7,139,219 131.53$



SFY 2015

Statewide

Standard Plan

M-CHIP

Non-Duals

All Ages

1,420,382118,365




29 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 97,792,869$ 138,367 31,243 706.76$ 1,840.11$Inpatient — BH (LME/MCO) 24,202$ 34 8 709.54$ 0.46$Outpatient Hospital 4,617,007$ 38,587 8,713 119.65$ 86.88$Emergency Room 3,011,032$ 10,639 2,402 283.02$ 56.66$Physician 63,028,574$ 143,507 32,403 439.20$ 1,185.97$FQHC/RHC 925,325$ 4,118 930 224.70$ 17.41$Other Clinic 8,713,145$ 20,153 4,550 432.36$ 163.95$Other Practitioner 10,927$ 308 70 35.48$ 0.21$Therapies -$ - - -$ -$Prescribed Drugs 2,490,950$ 82,371 18,599 30.24$ 46.87$Enhanced BH 186,772$ 6,032 1,362 30.96$ 3.51$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 62,669$ 14,131 3,191 4.43$ 1.18$LTSS – HCBS Waiver Services 583$ 42 9 13.88$ 0.01$Durable Medical Equipment 225,377$ 195,698 44,188 1.15$ 4.24$Lab and X-Ray 971,423$ 47,587 10,745 20.41$ 18.28$Optical 9,869$ 438 99 22.53$ 0.19$Limited Dental Services -$ - - -$ -$Transportation 539,183$ 42,429 9,580 12.71$ 10.15$Case Management 402$ 31 7 12.96$ 0.01$Patient-Centered Medical Home (PCMH) Payments 244,843$ 66,369 14,986 3.69$ 4.61$Subtotal (Covered Services) 182,855,151$ 810,840 3,440.68$

Capitation — PACE 882$ 33 7 26.71$ 0.02$Dental 333,237$ 5,271 1,190 63.22$ 6.27$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 334,119$ 5,304 6.29$Total (All) 183,189,269$ 816,144 3,446.97$



SFY 2015

Statewide

Standard Plan

Delivery Episode

Non-Duals

All Ages

53,1454,429




30 of 179


7.1.2 SFY 2015 Foster Children and Adopted Children (Non-Duals)

31 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,356,883$ 6,196 296 864.62$ 21.32$Inpatient — BH (LME/MCO) 8,550,227$ 13,265 634 644.55$ 34.03$Outpatient Hospital 4,113,885$ 15,939 761 258.10$ 16.37$Emergency Room 4,123,543$ 11,934 570 345.54$ 16.41$Physician 8,271,739$ 94,723 4,524 87.33$ 32.92$FQHC/RHC 511,686$ 4,612 220 110.94$ 2.04$Other Clinic 2,366,582$ 19,955 953 118.60$ 9.42$Other Practitioner 49,504$ 655 31 75.58$ 0.20$Therapies 4,421,273$ 37,708 1,801 117.25$ 17.60$Prescribed Drugs 34,800,119$ 255,708 12,212 136.09$ 138.50$Enhanced BH 109,033,009$ 967,904 46,225 112.65$ 433.93$B3 Services 325,576$ 64,566 3,084 5.04$ 1.30$LTSS – ICF/IID and Nursing Home 1,296,081$ 11,848 566 109.39$ 5.16$LTSS – State Plan Home and Community Based Services (HCBS) 672,218$ 142,222 6,792 4.73$ 2.68$LTSS – HCBS Waiver Services 1,658,218$ 252,406 12,054 6.57$ 6.60$Durable Medical Equipment 1,824,645$ 837,222 39,984 2.18$ 7.26$Lab and X-Ray 927,302$ 51,706 2,469 17.93$ 3.69$Optical 561,736$ 26,858 1,283 20.92$ 2.24$Limited Dental Services 91,545$ 3,677 176 24.90$ 0.36$Transportation 713,400$ 34,750 1,660 20.53$ 2.84$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,482,777$ 644,818 30,795 2.30$ 5.90$Subtotal (Covered Services) 191,151,948$ 3,498,673 760.75$

Capitation — PACE 20,878$ 32 2 652.45$ 0.08$Dental 5,590,460$ 128,165 6,121 43.62$ 22.25$Local Education Agency (LEA) 504,915$ 16,447 785 30.70$ 2.01$Children’s Developmental Services Agencies (CDSA) 840,516$ 33,080 1,580 25.41$ 3.35$Subtotal (Excluded Services) 6,956,769$ 177,724 27.69$Total (All) 198,108,716$ 3,676,397 788.44$



SFY 2015

Statewide

Foster Children & Adopted Children

All Population Groups

Non-Duals

All Ages

251,26720,939




32 of 179


7.1.3 SFY 2015 Behavioral Health Intellectual/Developmental Disability Tailored Plan (Non-Duals and Duals)

33 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 62,884,981$ 63,669 1,822 987.68$ 149.98$Inpatient — BH (LME/MCO) 11,952,896$ 17,100 489 699.00$ 28.51$Outpatient Hospital 27,404,273$ 72,940 2,088 375.71$ 65.36$Emergency Room 12,576,882$ 36,249 1,037 346.96$ 30.00$Physician 39,962,223$ 300,958 8,613 132.78$ 95.31$FQHC/RHC 1,065,373$ 9,533 273 111.75$ 2.54$Other Clinic 4,439,869$ 38,318 1,097 115.87$ 10.59$Other Practitioner 100,335$ 1,511 43 66.40$ 0.24$Therapies 36,321,345$ 314,443 8,999 115.51$ 86.63$Prescribed Drugs 94,430,451$ 569,519 16,300 165.81$ 225.22$Enhanced BH 90,872,583$ 1,362,057 38,982 66.72$ 216.73$B3 Services 6,671,350$ 1,213,955 34,743 5.50$ 15.91$LTSS – ICF/IID and Nursing Home 41,725,877$ 141,045 4,037 295.83$ 99.52$LTSS – State Plan Home and Community Based Services (HCBS) 32,491,808$ 5,821,269 166,605 5.58$ 77.49$LTSS – HCBS Waiver Services 112,003,004$ 21,581,513 617,663 5.19$ 267.13$Durable Medical Equipment 30,794,498$ 12,534,435 358,736 2.46$ 73.44$Lab and X-Ray 1,665,388$ 94,088 2,693 17.70$ 3.97$Optical 619,330$ 34,025 974 18.20$ 1.48$Limited Dental Services 379,120$ 15,220 436 24.91$ 0.90$Transportation 2,010,524$ 144,890 4,147 13.88$ 4.80$Case Management 3,848$ 297 9 12.96$ 0.01$Patient-Centered Medical Home (PCMH) Payments 4,381,214$ 1,164,614 33,331 3.76$ 10.45$Subtotal (Covered Services) 614,757,173$ 45,531,648 1,466.20$

Capitation — PACE 114,011$ 99 3 1,151.62$ 0.27$Dental 6,560,606$ 153,701 4,399 42.68$ 15.65$Local Education Agency (LEA) 6,160,811$ 203,382 5,821 30.29$ 14.69$Children’s Developmental Services Agencies (CDSA) 8,958,218$ 360,681 10,323 24.84$ 21.37$Subtotal (Excluded Services) 21,793,645$ 717,863 51.98$Total (All) 636,550,818$ 46,249,512 1,518.17$



SFY 2015

Statewide

BH I/DD Tailored Plan

Default – I/DD

Non-Duals

Child (<21)

419,28734,941




34 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 20,290,192$ 25,846 1,886 785.05$ 123.41$Inpatient — BH (LME/MCO) 14,871,649$ 21,909 1,599 678.80$ 90.45$Outpatient Hospital 10,271,915$ 33,085 2,415 310.47$ 62.47$Emergency Room 15,324,833$ 31,340 2,287 488.98$ 93.21$Physician 16,473,481$ 135,149 9,864 121.89$ 100.19$FQHC/RHC 892,454$ 8,305 606 107.46$ 5.43$Other Clinic 1,453,638$ 4,650 339 312.60$ 8.84$Other Practitioner 193,178$ 3,022 221 63.92$ 1.17$Therapies 640$ 8 1 80.03$ 0.00$Prescribed Drugs 83,043,947$ 693,776 50,635 119.70$ 505.08$Enhanced BH 25,964,470$ 2,892,192 211,087 8.98$ 157.92$B3 Services 14,661,439$ 1,443,897 105,383 10.15$ 89.17$LTSS – ICF/IID and Nursing Home 127,564,066$ 355,467 25,944 358.86$ 775.86$LTSS – State Plan Home and Community Based Services (HCBS) 29,594,184$ 7,166,137 523,022 4.13$ 179.99$LTSS – HCBS Waiver Services 214,326,241$ 32,678,539 2,385,048 6.56$ 1,303.55$Durable Medical Equipment 10,380,361$ 5,881,843 429,287 1.76$ 63.13$Lab and X-Ray 3,018,874$ 165,465 12,076 18.24$ 18.36$Optical 161,886$ 2,389 174 67.76$ 0.98$Limited Dental Services 6$ 20 1 0.31$ 0.00$Transportation 5,969,907$ 447,466 32,658 13.34$ 36.31$Case Management 38,685$ 3,021 220 12.81$ 0.24$Patient-Centered Medical Home (PCMH) Payments 2,204,398$ 273,822 19,985 8.05$ 13.41$Subtotal (Covered Services) 596,700,445$ 52,267,348 3,629.19$

Capitation — PACE 212,439$ 133 10 1,597.29$ 1.29$Dental 2,880,107$ 48,045 3,507 59.95$ 17.52$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 3,092,546$ 48,178 18.81$Total (All) 599,792,990$ 52,315,526 3,648.00$



SFY 2015

Statewide


Default – I/DD

Non-Duals

Adult (21+)

164,41713,701




35 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,241,093$ 18,146 906 233.73$ 17.64$Inpatient — BH (LME/MCO) 3,501,119$ 15,373 768 227.74$ 14.57$Outpatient Hospital 2,568,862$ 27,489 1,372 93.45$ 10.69$Emergency Room 2,679,434$ 30,131 1,504 88.93$ 11.15$Physician 4,999,685$ 219,217 10,944 22.81$ 20.80$FQHC/RHC 255,422$ 9,627 481 26.53$ 1.06$Other Clinic 296,857$ 2,306 115 128.73$ 1.24$Other Practitioner 76,653$ 6,156 307 12.45$ 0.32$Therapies 21,458$ 205 10 104.67$ 0.09$Prescribed Drugs 7,089,538$ 79,672 3,978 88.98$ 29.50$Enhanced BH 25,765,247$ 3,757,245 187,582 6.86$ 107.19$B3 Services 13,607,478$ 1,442,473 72,016 9.43$ 56.61$LTSS – ICF/IID and Nursing Home 317,007,674$ 769,070 38,396 412.20$ 1,318.89$LTSS – State Plan Home and Community Based Services (HCBS) 69,783,489$ 19,304,732 963,795 3.61$ 290.33$LTSS – HCBS Waiver Services 262,242,039$ 34,452,489 1,720,052 7.61$ 1,091.04$Durable Medical Equipment 7,343,031$ 6,840,323 341,505 1.07$ 30.55$Lab and X-Ray 167,146$ 14,070 702 11.88$ 0.70$Optical 77,195$ 5,681 284 13.59$ 0.32$Limited Dental Services 151$ 11 1 13.72$ 0.00$Transportation 10,023,956$ 675,562 33,728 14.84$ 41.70$Case Management 34,983$ 2,709 135 12.91$ 0.15$Patient-Centered Medical Home (PCMH) Payments 2,773,241$ 329,483 16,450 8.42$ 11.54$Subtotal (Covered Services) 734,555,751$ 68,002,170 3,056.08$

Capitation — PACE 819,011$ 356 18 2,300.59$ 3.41$Dental 3,575,255$ 62,891 3,140 56.85$ 14.87$Local Education Agency (LEA) 10,410$ 272 14 38.27$ 0.04$Children’s Developmental Services Agencies (CDSA) 519$ 22 1 23.61$ 0.00$Subtotal (Excluded Services) 4,405,196$ 63,541 18.33$Total (All) 738,960,947$ 68,065,711 3,074.41$



SFY 2015

Statewide


Default – I/DD

Duals

All Ages

240,35920,030




36 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,113,216$ 7,140 465 716.18$ 27.77$Inpatient — BH (LME/MCO) 22,444,212$ 32,725 2,132 685.85$ 121.88$Outpatient Hospital 3,029,220$ 12,862 838 235.52$ 16.45$Emergency Room 8,300,341$ 22,166 1,444 374.46$ 45.07$Physician 6,432,101$ 68,624 4,472 93.73$ 34.93$FQHC/RHC 517,249$ 4,685 305 110.40$ 2.81$Other Clinic 1,331,745$ 10,532 686 126.44$ 7.23$Other Practitioner 34,152$ 499 33 68.44$ 0.19$Therapies 1,076,042$ 9,439 615 114.00$ 5.84$Prescribed Drugs 37,490,194$ 254,638 16,593 147.23$ 203.58$Enhanced BH 242,403,214$ 2,359,593 153,758 102.73$ 1,316.31$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 1,364$ 13 1 104.90$ 0.01$LTSS – State Plan Home and Community Based Services (HCBS) 265,887$ 67,222 4,380 3.96$ 1.44$LTSS – HCBS Waiver Services 803$ 71 5 11.31$ 0.00$Durable Medical Equipment 553,025$ 313,933 20,457 1.76$ 3.00$Lab and X-Ray 1,680,322$ 87,729 5,717 19.15$ 9.12$Optical 417,130$ 20,296 1,323 20.55$ 2.27$Limited Dental Services 3,051$ 123 8 24.81$ 0.02$Transportation 686,592$ 68,466 4,461 10.03$ 3.73$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,487,953$ 501,323 32,668 2.97$ 8.08$Subtotal (Covered Services) 333,267,813$ 3,842,080 1,809.72$

Capitation — PACE 6,445$ 31 2 207.91$ 0.03$Dental 3,925,869$ 83,133 5,417 47.22$ 21.32$Local Education Agency (LEA) 237,681$ 6,829 445 34.80$ 1.29$Children’s Developmental Services Agencies (CDSA) 145,985$ 6,046 394 24.15$ 0.79$Subtotal (Excluded Services) 4,315,981$ 96,039 23.44$Total (All) 337,583,794$ 3,938,119 1,833.16$



SFY 2015

Statewide


Default – SPMI/SED

Non-Duals

Child (<21)

184,15415,346




37 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 11,863,707$ 13,954 1,544 850.18$ 109.42$Inpatient — BH (LME/MCO) 12,415,033$ 18,756 2,076 661.94$ 114.50$Outpatient Hospital 6,245,757$ 21,068 2,332 296.46$ 57.60$Emergency Room 17,803,851$ 37,173 4,114 478.94$ 164.21$Physician 12,541,664$ 95,717 10,594 131.03$ 115.67$FQHC/RHC 870,787$ 7,905 875 110.15$ 8.03$Other Clinic 995,023$ 4,174 462 238.38$ 9.18$Other Practitioner 82,894$ 1,149 127 72.14$ 0.76$Therapies 44$ 2 0 22.09$ 0.00$Prescribed Drugs 49,485,663$ 393,697 43,573 125.69$ 456.41$Enhanced BH 56,343,800$ 4,191,121 463,859 13.44$ 519.66$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 134,721$ 872 97 154.49$ 1.24$LTSS – State Plan Home and Community Based Services (HCBS) 6,018,129$ 1,617,891 179,063 3.72$ 55.51$LTSS – HCBS Waiver Services 989$ 73 8 13.55$ 0.01$Durable Medical Equipment 2,219,517$ 836,341 92,563 2.65$ 20.47$Lab and X-Ray 8,693,926$ 427,574 47,322 20.33$ 80.18$Optical 77,655$ 1,191 132 65.20$ 0.72$Limited Dental Services 0$ 1 0 0.31$ 0.00$Transportation 3,249,041$ 295,471 32,702 11.00$ 29.97$Case Management 73,556$ 5,756 637 12.78$ 0.68$Patient-Centered Medical Home (PCMH) Payments 1,143,628$ 179,777 19,897 6.36$ 10.55$Subtotal (Covered Services) 190,259,387$ 8,149,664 1,754.77$

Capitation — PACE 2,475$ 16 2 154.71$ 0.02$Dental 2,660,688$ 39,168 4,335 67.93$ 24.54$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 2,663,163$ 39,184 24.56$Total (All) 192,922,550$ 8,188,848 1,779.33$



SFY 2015

Statewide



Non-Duals

Adult (21+)

108,4249,035




38 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,393,513$ 5,204 1,011 267.79$ 22.56$Inpatient — BH (LME/MCO) 1,294,230$ 5,996 1,165 215.86$ 20.96$Outpatient Hospital 824,408$ 9,214 1,790 89.47$ 13.35$Emergency Room 1,625,729$ 15,798 3,070 102.90$ 26.32$Physician 1,440,895$ 58,042 11,277 24.82$ 23.33$FQHC/RHC 92,032$ 3,389 658 27.15$ 1.49$Other Clinic 75,832$ 785 153 96.60$ 1.23$Other Practitioner 18,873$ 1,198 233 15.75$ 0.31$Therapies 111$ 2 0 55.51$ 0.00$Prescribed Drugs 2,711,716$ 23,711 4,607 114.37$ 43.91$Enhanced BH 37,508,793$ 4,301,156 835,703 8.72$ 607.32$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 196,931$ 1,433 278 137.42$ 3.19$LTSS – State Plan Home and Community Based Services (HCBS) 8,728,035$ 2,496,937 485,148 3.50$ 141.32$LTSS – HCBS Waiver Services 16$ 2 0 7.80$ 0.00$Durable Medical Equipment 570,665$ 341,155 66,286 1.67$ 9.24$Lab and X-Ray 156,905$ 9,785 1,901 16.04$ 2.54$Optical 15,265$ 1,099 214 13.89$ 0.25$Limited Dental Services -$ - - -$ -$Transportation 2,305,446$ 278,779 54,166 8.27$ 37.33$Case Management 43,254$ 3,349 651 12.92$ 0.70$Patient-Centered Medical Home (PCMH) Payments 763,661$ 91,552 17,788 8.34$ 12.36$Subtotal (Covered Services) 59,766,308$ 7,648,587 967.70$

Capitation — PACE 36,242$ 30 6 1,208.06$ 0.59$Dental 1,290,994$ 19,734 3,834 65.42$ 20.90$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 1,327,235$ 19,764 21.49$Total (All) 61,093,544$ 7,668,351 989.19$



SFY 2015

Statewide



Duals

All Ages

61,7615,147




39 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 258,609$ 311 481 831.43$ 33.32$Inpatient — BH (LME/MCO) 115,188$ 176 271 656.25$ 14.84$Outpatient Hospital 139,513$ 512 792 272.49$ 17.97$Emergency Room 463,319$ 1,196 1,849 387.39$ 59.69$Physician 294,955$ 2,305 3,564 127.96$ 38.00$FQHC/RHC 20,633$ 188 291 109.75$ 2.66$Other Clinic 73,616$ 402 622 183.12$ 9.48$Other Practitioner 1,147$ 11 17 104.28$ 0.15$Therapies 4,603$ 62 96 74.24$ 0.59$Prescribed Drugs 291,800$ 4,642 7,177 62.86$ 37.59$Enhanced BH 2,661,147$ 57,178 88,396 46.54$ 342.84$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 12,388$ 960 1,484 12.90$ 1.60$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 9,020$ 4,891 7,561 1.84$ 1.16$Lab and X-Ray 656,933$ 30,715 47,485 21.39$ 84.63$Optical 9,549$ 454 702 21.03$ 1.23$Limited Dental Services -$ - - -$ -$Transportation 31,866$ 1,524 2,356 20.91$ 4.11$Case Management 2,488$ 192 297 12.96$ 0.32$Patient-Centered Medical Home (PCMH) Payments 55,964$ 20,561 31,787 2.72$ 7.21$Subtotal (Covered Services) 5,102,739$ 126,279 657.40$

Capitation — PACE -$ - - -$ -$Dental 149,228$ 2,462 3,806 60.61$ 19.23$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) 2,097$ 92 142 22.80$ 0.27$Subtotal (Excluded Services) 151,326$ 2,554 19.50$Total (All) 5,254,065$ 128,833 676.90$



SFY 2015

Statewide


Default – SUD

Non-Duals

Child (<21)

7,762647




40 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 6,678,437$ 7,814 1,228 854.71$ 87.48$Inpatient — BH (LME/MCO) 647,265$ 964 152 671.49$ 8.48$Outpatient Hospital 3,245,740$ 10,310 1,621 314.81$ 42.52$Emergency Room 6,852,938$ 14,910 2,344 459.61$ 89.77$Physician 8,157,094$ 52,564 8,263 155.18$ 106.85$FQHC/RHC 368,796$ 3,209 504 114.92$ 4.83$Other Clinic 577,919$ 2,793 439 206.91$ 7.57$Other Practitioner 42,043$ 533 84 78.88$ 0.55$Therapies -$ - - -$ -$Prescribed Drugs 13,782,478$ 128,368 20,178 107.37$ 180.54$Enhanced BH 26,379,356$ 917,824 144,274 28.74$ 345.55$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 24,572$ 157 25 156.51$ 0.32$LTSS – State Plan Home and Community Based Services (HCBS) 1,805,342$ 455,567 71,611 3.96$ 23.65$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 715,397$ 227,689 35,791 3.14$ 9.37$Lab and X-Ray 14,494,729$ 663,950 104,367 21.83$ 189.87$Optical 32,190$ 495 78 65.03$ 0.42$Limited Dental Services -$ - - -$ -$Transportation 844,098$ 45,762 7,193 18.45$ 11.06$Case Management 39,925$ 3,088 485 12.93$ 0.52$Patient-Centered Medical Home (PCMH) Payments 607,471$ 128,345 20,175 4.73$ 7.96$Subtotal (Covered Services) 85,295,789$ 2,664,342 1,117.31$

Capitation — PACE 846$ 18 3 46.99$ 0.01$Dental 2,247,444$ 31,041 4,879 72.40$ 29.44$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 2,248,290$ 31,059 29.45$Total (All) 87,544,079$ 2,695,401 1,146.77$



SFY 2015

Statewide


Default – SUD

Non-Duals

Adult (21+)

76,3406,362




41 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 389,877$ 709 565 549.88$ 25.88$Inpatient — BH (LME/MCO) 41,541$ 145 115 287.06$ 2.76$Outpatient Hospital 167,319$ 1,947 1,551 85.94$ 11.11$Emergency Room 264,146$ 3,136 2,498 84.23$ 17.54$Physician 295,946$ 12,367 9,853 23.93$ 19.65$FQHC/RHC 20,287$ 762 607 26.62$ 1.35$Other Clinic 13,275$ 137 109 96.89$ 0.88$Other Practitioner 3,166$ 142 113 22.30$ 0.21$Therapies -$ - - -$ -$Prescribed Drugs 355,117$ 2,917 2,324 121.74$ 23.58$Enhanced BH 5,598,244$ 164,927 131,390 33.94$ 371.66$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 38,612$ 370 295 104.35$ 2.56$LTSS – State Plan Home and Community Based Services (HCBS) 1,428,595$ 385,464 307,081 3.71$ 94.84$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 89,133$ 52,607 41,910 1.69$ 5.92$Lab and X-Ray 77,336$ 3,918 3,121 19.74$ 5.13$Optical 3,481$ 265 211 13.14$ 0.23$Limited Dental Services -$ - - -$ -$Transportation 239,009$ 26,760 21,318 8.93$ 15.87$Case Management 20,928$ 1,622 1,292 12.90$ 1.39$Patient-Centered Medical Home (PCMH) Payments 188,983$ 22,438 17,875 8.42$ 12.55$Subtotal (Covered Services) 9,234,996$ 680,634 613.09$

Capitation — PACE 82$ 2 2 40.86$ 0.01$Dental 272,643$ 3,711 2,956 73.47$ 18.10$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 272,725$ 3,713 18.11$Total (All) 9,507,721$ 684,347 631.20$



SFY 2015

Statewide


Default – SUD

Duals

All Ages

15,0631,255




42 of 179


7.1.4 SFY 2015 Non-Dual Long Term Services and Supports Population

43 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 7,062,294$ 5,605 3,020 1,260.07$ 317.08$Inpatient — BH (LME/MCO) 21,176$ 36 19 586.51$ 0.95$Outpatient Hospital 3,963,289$ 10,561 5,690 375.28$ 177.94$Emergency Room 964,726$ 2,028 1,093 475.71$ 43.31$Physician 3,535,941$ 26,310 14,175 134.40$ 158.75$FQHC/RHC 25,895$ 228 123 113.57$ 1.16$Other Clinic 134,050$ 960 517 139.63$ 6.02$Other Practitioner 9,376$ 143 77 65.57$ 0.42$Therapies 4,104,149$ 33,249 17,914 123.44$ 184.27$Prescribed Drugs 17,064,245$ 78,759 42,433 216.66$ 766.14$Enhanced BH 342,161$ 11,841 6,380 28.90$ 15.36$B3 Services 174,241$ 32,608 17,568 5.34$ 7.82$LTSS – ICF/IID and Nursing Home 630,908$ 1,740 937 362.58$ 28.33$LTSS – State Plan Home and Community Based Services (HCBS) 5,269,933$ 1,149,457 619,291 4.58$ 236.61$LTSS – HCBS Waiver Services 86,438,670$ 14,002,759 7,544,251 6.17$ 3,880.87$Durable Medical Equipment 18,293,109$ 6,150,574 3,313,738 2.97$ 821.31$Lab and X-Ray 31,438$ 2,213 1,192 14.21$ 1.41$Optical 24,630$ 1,665 897 14.79$ 1.11$Limited Dental Services 3,374$ 143 77 23.60$ 0.15$Transportation 419,632$ 28,962 15,604 14.49$ 18.84$Case Management 207$ 16 9 12.96$ 0.01$Patient-Centered Medical Home (PCMH) Payments 315,927$ 56,472 30,425 5.59$ 14.18$Subtotal (Covered Services) 148,829,374$ 21,596,329 6,682.05$

Capitation — PACE 1,224$ 3 2 408.02$ 0.05$Dental 262,317$ 5,984 3,224 43.84$ 11.78$Local Education Agency (LEA) 713,057$ 34,364 18,514 20.75$ 32.01$Children’s Developmental Services Agencies (CDSA) 183,866$ 8,012 4,317 22.95$ 8.26$Subtotal (Excluded Services) 1,160,465$ 48,363 52.10$Total (All) 149,989,839$ 21,644,692 6,734.16$



SFY 2015

Statewide

Non-Dual LTSS Population

CAP/C

Non-Duals

All Ages

22,2731,856




44 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,913,335$ 7,005 4,558 844.19$ 320.65$Inpatient — BH (LME/MCO) 264,674$ 320 208 827.77$ 14.35$Outpatient Hospital 2,524,372$ 7,090 4,613 356.05$ 136.88$Emergency Room 2,008,801$ 3,539 2,303 567.62$ 108.93$Physician 3,622,815$ 26,828 17,457 135.04$ 196.44$FQHC/RHC 155,478$ 1,508 981 103.10$ 8.43$Other Clinic 390,829$ 540 351 723.74$ 21.19$Other Practitioner 40,412$ 633 412 63.84$ 2.19$Therapies 19,277$ 106 69 181.85$ 1.05$Prescribed Drugs 17,107,350$ 143,579 93,425 119.15$ 927.63$Enhanced BH 564,101$ 19,887 12,940 28.37$ 30.59$B3 Services 225,300$ 31,979 20,809 7.05$ 12.22$LTSS – ICF/IID and Nursing Home 103,933$ 638 415 162.89$ 5.64$LTSS – State Plan Home and Community Based Services (HCBS) 3,932,410$ 784,330 510,355 5.01$ 213.23$LTSS – HCBS Waiver Services 33,968,878$ 10,519,394 6,844,850 3.23$ 1,841.93$Durable Medical Equipment 4,672,876$ 1,353,806 880,906 3.45$ 253.38$Lab and X-Ray 296,448$ 17,407 11,327 17.03$ 16.07$Optical 32,891$ 512 333 64.24$ 1.78$Limited Dental Services 0$ 1 1 0.31$ 0.00$Transportation 1,502,021$ 57,352 37,318 26.19$ 81.45$Case Management 2,341$ 181 118 12.94$ 0.13$Patient-Centered Medical Home (PCMH) Payments 277,660$ 33,024 21,488 8.41$ 15.06$Subtotal (Covered Services) 77,626,202$ 13,009,659 4,209.21$

Capitation — PACE 849$ 5 3 169.82$ 0.05$Dental 248,412$ 3,860 2,512 64.36$ 13.47$Local Education Agency (LEA) 3,012$ 252 164 11.95$ 0.16$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 252,273$ 4,117 13.68$Total (All) 77,878,475$ 13,013,776 4,222.89$



SFY 2015

Statewide


CAP/DA

Non-Duals

All Ages

18,4421,537




45 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 13,528,112$ 16,173 9,742 836.47$ 679.09$Inpatient — BH (LME/MCO) 410,597$ 668 403 614.42$ 20.61$Outpatient Hospital 2,567,154$ 10,062 6,061 255.13$ 128.87$Emergency Room 2,017,600$ 3,698 2,228 545.59$ 101.28$Physician 6,889,582$ 51,876 31,249 132.81$ 345.85$FQHC/RHC 186,911$ 1,796 1,082 104.07$ 9.38$Other Clinic 1,004,400$ 798 481 1,258.62$ 50.42$Other Practitioner 71,239$ 991 597 71.88$ 3.58$Therapies -$ - - -$ -$Prescribed Drugs 16,157,752$ 192,562 115,995 83.91$ 811.09$Enhanced BH 392,099$ 10,242 6,170 38.28$ 19.68$B3 Services 9,724$ 773 466 12.58$ 0.49$LTSS – ICF/IID and Nursing Home 79,050,419$ 462,332 278,499 170.98$ 3,968.20$LTSS – State Plan Home and Community Based Services (HCBS) 3,892,786$ 276,293 166,433 14.09$ 195.41$LTSS – HCBS Waiver Services 51,034$ 9,907 5,968 5.15$ 2.56$Durable Medical Equipment 1,298,903$ 565,344 340,552 2.30$ 65.20$Lab and X-Ray 563,094$ 40,594 24,453 13.87$ 28.27$Optical 54,425$ 798 481 68.20$ 2.73$Limited Dental Services -$ - - -$ -$Transportation 1,175,819$ 118,833 71,582 9.89$ 59.02$Case Management 1,267$ 98 59 12.93$ 0.06$Patient-Centered Medical Home (PCMH) Payments 53,148$ 6,528 3,932 8.14$ 2.67$Subtotal (Covered Services) 129,376,065$ 1,770,366 6,494.46$

Capitation — PACE 16,821$ 19 11 885.31$ 0.84$Dental 321,301$ 4,724 2,846 68.01$ 16.13$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 338,122$ 4,743 16.97$Total (All) 129,714,187$ 1,775,109 6,511.43$



SFY 2015

Statewide


Long-Term Nursing Facility

Non-Duals

All Ages

19,9211,660




46 of 179


7.1.5 SFY 2015 Dual Eligibles

47 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 41,242,485$ 198,094 1,074 208.20$ 18.63$Inpatient — BH (LME/MCO) 1,383,594$ 6,694 36 206.69$ 0.63$Outpatient Hospital 32,496,199$ 370,011 2,006 87.82$ 14.68$Emergency Room 22,542,413$ 232,918 1,263 96.78$ 10.19$Physician 58,286,561$ 2,072,194 11,236 28.13$ 26.34$FQHC/RHC 2,828,186$ 112,882 612 25.05$ 1.28$Other Clinic 4,893,925$ 47,963 260 102.04$ 2.21$Other Practitioner 609,735$ 50,293 273 12.12$ 0.28$Therapies 17,943$ 402 2 44.63$ 0.01$Prescribed Drugs 39,222,803$ 457,455 2,480 85.74$ 17.72$Enhanced BH 9,184,449$ 844,955 4,581 10.87$ 4.15$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 11,872,798$ 171,765 931 69.12$ 5.36$LTSS – State Plan Home and Community Based Services (HCBS) 329,056,284$ 90,146,655 488,781 3.65$ 148.68$LTSS – HCBS Waiver Services 177,158$ 49,776 270 3.56$ 0.08$Durable Medical Equipment 29,804,426$ 20,911,958 113,386 1.43$ 13.47$Lab and X-Ray 1,278,415$ 100,176 543 12.76$ 0.58$Optical 779,100$ 101,687 551 7.66$ 0.35$Limited Dental Services 50$ 2 0 24.90$ 0.00$Transportation 21,731,128$ 1,541,457 8,358 14.10$ 9.82$Case Management 549,437$ 42,587 231 12.90$ 0.25$Patient-Centered Medical Home (PCMH) Payments 26,326,275$ 3,104,756 16,834 8.48$ 11.90$Subtotal (Covered Services) 634,283,363$ 120,564,679 286.59$

Capitation — PACE 26,350,476$ 8,820 48 2,987.58$ 11.91$Dental 28,990,699$ 431,190 2,338 67.23$ 13.10$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 55,341,176$ 440,010 25.01$Total (All) 689,624,538$ 121,004,689 311.60$



SFY 2015

Statewide

Dual Eligibles

Non-LTSS Populations

Duals

All Ages

2,213,177184,431




48 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 8,225,184$ 31,347 1,318 262.39$ 28.82$Inpatient — BH (LME/MCO) 334,037$ 982 41 340.06$ 1.17$Outpatient Hospital 2,768,958$ 34,600 1,455 80.03$ 9.70$Emergency Room 2,711,621$ 31,225 1,313 86.84$ 9.50$Physician 7,464,681$ 403,644 16,971 18.49$ 26.15$FQHC/RHC 411,319$ 19,909 837 20.66$ 1.44$Other Clinic 767,257$ 5,493 231 139.67$ 2.69$Other Practitioner 90,615$ 8,116 341 11.16$ 0.32$Therapies 11,137$ 143 6 77.88$ 0.04$Prescribed Drugs 2,689,916$ 43,143 1,814 62.35$ 9.42$Enhanced BH 879,390$ 78,303 3,292 11.23$ 3.08$B3 Services 547,624$ 73,364 3,085 7.46$ 1.92$LTSS – ICF/IID and Nursing Home 659,199,434$ 4,739,593 199,270 139.08$ 2,309.60$LTSS – State Plan Home and Community Based Services (HCBS) 28,166,439$ 3,478,188 146,236 8.10$ 98.69$LTSS – HCBS Waiver Services 196,087,765$ 60,869,430 2,559,179 3.22$ 687.02$Durable Medical Equipment 5,502,909$ 4,463,011 187,642 1.23$ 19.28$Lab and X-Ray 162,135$ 30,928 1,300 5.24$ 0.57$Optical 75,069$ 12,718 535 5.90$ 0.26$Limited Dental Services 0$ 1 0 0.31$ 0.00$Transportation 6,613,109$ 928,799 39,050 7.12$ 23.17$Case Management 1,037$ 80 3 12.96$ 0.00$Patient-Centered Medical Home (PCMH) Payments 1,481,571$ 172,803 7,265 8.57$ 5.19$Subtotal (Covered Services) 924,191,206$ 75,425,821 3,238.04$

Capitation — PACE 478,687$ 251 11 1,907.12$ 1.68$Dental 2,705,326$ 42,005 1,766 64.40$ 9.48$Local Education Agency (LEA) 2,462$ 102 4 24.13$ 0.01$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 3,186,475$ 42,358 11.16$Total (All) 927,377,681$ 75,468,179 3,249.20$



SFY 2015

Statewide

Dual Eligibles

LTSS Populations

Duals

All Ages

285,41723,785




49 of 179


SFY 2016 Population Group Exhibits7.2Cost and utilization information for the July 1, 2015 through June 30, 2016 (SFY 2016) time period is illustrated inSection 7.2.

50 of 179



51 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 15,502,615$ 22,668 31,623 683.90$ 1,802.21$Inpatient — BH (LME/MCO) -$ - - -$ -$Outpatient Hospital 669,242$ 2,133 2,976 313.69$ 77.80$Emergency Room 296,217$ 876 1,222 338.04$ 34.44$Physician 9,370,623$ 34,515 48,149 271.50$ 1,089.35$FQHC/RHC 16,317$ 134 187 121.57$ 1.90$Other Clinic 182,773$ 1,771 2,470 103.23$ 21.25$Other Practitioner -$ - - -$ -$Therapies 127,325$ 1,171 1,634 108.73$ 14.80$Prescribed Drugs 2,719,068$ 6,194 8,641 438.98$ 316.10$Enhanced BH 13,696$ 837 1,168 16.36$ 1.59$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 893,478$ 81,940 114,309 10.90$ 103.87$LTSS – HCBS Waiver Services 537$ 38 53 14.14$ 0.06$Durable Medical Equipment 749,647$ 117,413 163,793 6.38$ 87.15$Lab and X-Ray 9,651$ 520 726 18.54$ 1.12$Optical 1,805$ 106 148 17.02$ 0.21$Limited Dental Services 7,328$ 296 413 24.75$ 0.85$Transportation 73,650$ 8,290 11,565 8.88$ 8.56$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 50,615$ 15,129 21,106 3.35$ 5.88$Subtotal (Covered Services) 30,684,586$ 294,033 3,567.15$

Capitation — PACE -$ - - -$ -$Dental 408$ 14 20 29.17$ 0.05$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) 197,273$ 7,786 10,861 25.34$ 22.93$Subtotal (Excluded Services) 197,681$ 7,800 22.98$Total (All) 30,882,268$ 301,832 3,590.13$



SFY 2016

Statewide

Standard Plan


Non-Duals

Newborn (<1)

8,602717




52 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 21,878,473$ 18,552 519 1,179.33$ 51.05$Inpatient — BH (LME/MCO) 1,672,339$ 2,599 73 643.40$ 3.90$Outpatient Hospital 19,361,204$ 41,323 1,157 468.54$ 45.17$Emergency Room 9,238,317$ 27,241 763 339.13$ 21.56$Physician 15,953,738$ 159,156 4,456 100.24$ 37.22$FQHC/RHC 779,166$ 7,189 201 108.38$ 1.82$Other Clinic 2,301,439$ 18,579 520 123.87$ 5.37$Other Practitioner 70,076$ 945 26 74.13$ 0.16$Therapies 7,178,323$ 63,179 1,769 113.62$ 16.75$Prescribed Drugs 99,829,152$ 386,316 10,817 258.41$ 232.93$Enhanced BH 7,521,651$ 111,314 3,117 67.57$ 17.55$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 10,487,731$ 1,525,089 42,701 6.88$ 24.47$LTSS – HCBS Waiver Services 12,839$ 3,164 89 4.06$ 0.03$Durable Medical Equipment 9,080,039$ 3,237,811 90,656 2.80$ 21.19$Lab and X-Ray 987,933$ 54,491 1,526 18.13$ 2.31$Optical 797,760$ 41,821 1,171 19.08$ 1.86$Limited Dental Services 41,854$ 1,679 47 24.93$ 0.10$Transportation 1,162,407$ 42,269 1,184 27.50$ 2.71$Case Management 6,309$ 487 14 12.95$ 0.01$Patient-Centered Medical Home (PCMH) Payments 6,215,036$ 1,223,750 34,264 5.08$ 14.50$Subtotal (Covered Services) 214,575,789$ 6,966,954 500.66$

Capitation — PACE 173,596$ 470 13 369.31$ 0.41$Dental 7,249,069$ 158,833 4,447 45.64$ 16.91$Local Education Agency (LEA) 2,714,340$ 81,397 2,279 33.35$ 6.33$Children’s Developmental Services Agencies (CDSA) 188,911$ 8,083 226 23.37$ 0.44$Subtotal (Excluded Services) 10,325,916$ 248,783 24.09$Total (All) 224,901,706$ 7,215,737 524.76$



SFY 2016

Statewide

Standard Plan


Non-Duals

Child (1-20)

428,58435,715




53 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 237,086,446$ 250,686 2,421 945.75$ 190.80$Inpatient — BH (LME/MCO) 8,993,728$ 13,579 131 662.31$ 7.24$Outpatient Hospital 143,193,777$ 300,930 2,906 475.84$ 115.24$Emergency Room 96,052,719$ 185,104 1,788 518.91$ 77.30$Physician 161,835,386$ 1,133,701 10,948 142.75$ 130.24$FQHC/RHC 8,886,444$ 80,710 779 110.10$ 7.15$Other Clinic 14,626,691$ 23,337 225 626.76$ 11.77$Other Practitioner 1,367,215$ 17,916 173 76.31$ 1.10$Therapies 7,136$ 127 1 56.03$ 0.01$Prescribed Drugs 544,228,167$ 4,149,113 40,069 131.17$ 437.98$Enhanced BH 17,158,464$ 347,793 3,359 49.34$ 13.81$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 1,589,514$ 10,339 100 153.73$ 1.28$LTSS – State Plan Home and Community Based Services (HCBS) 98,166,662$ 20,348,832 196,514 4.82$ 79.00$LTSS – HCBS Waiver Services 94,170$ 30,921 299 3.05$ 0.08$Durable Medical Equipment 47,404,615$ 16,229,219 156,730 2.92$ 38.15$Lab and X-Ray 17,119,413$ 947,047 9,146 18.08$ 13.78$Optical 1,236,246$ 19,235 186 64.27$ 0.99$Limited Dental Services 1$ 4 0 0.25$ 0.00$Transportation 18,432,016$ 491,730 4,749 37.48$ 14.83$Case Management 544,051$ 42,083 406 12.93$ 0.44$Patient-Centered Medical Home (PCMH) Payments 15,422,344$ 2,092,743 20,210 7.37$ 12.41$Subtotal (Covered Services) 1,433,445,207$ 46,715,151 1,153.59$

Capitation — PACE 2,732,346$ 3,508 34 778.82$ 2.20$Dental 20,331,664$ 289,093 2,792 70.33$ 16.36$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 23,064,010$ 292,601 18.56$Total (All) 1,456,509,218$ 47,007,752 1,172.16$



SFY 2016

Statewide

Standard Plan


Non-Duals

Adult (21+)

1,242,590103,549




54 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 146,112,171$ 261,685 3,593 558.35$ 167.20$Inpatient — BH (LME/MCO) -$ - - -$ -$Outpatient Hospital 9,006,639$ 59,755 821 150.73$ 10.31$Emergency Room 18,489,221$ 77,114 1,059 239.77$ 21.16$Physician 64,943,142$ 725,925 9,969 89.46$ 74.32$FQHC/RHC 4,050,700$ 37,287 512 108.64$ 4.64$Other Clinic 32,046,520$ 318,333 4,371 100.67$ 36.67$Other Practitioner 26,595$ 660 9 40.29$ 0.03$Therapies 620,409$ 6,432 88 96.46$ 0.71$Prescribed Drugs 11,708,546$ 264,695 3,635 44.23$ 13.40$Enhanced BH 32,969$ 1,640 23 20.10$ 0.04$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 888,196$ 55,235 758 16.08$ 1.02$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 4,453,826$ 512,410 7,037 8.69$ 5.10$Lab and X-Ray 747,100$ 38,046 522 19.64$ 0.85$Optical 33,954$ 963 13 35.26$ 0.04$Limited Dental Services 1,909,455$ 76,726 1,054 24.89$ 2.19$Transportation 1,047,242$ 89,300 1,226 11.73$ 1.20$Case Management 207$ 16 0 12.96$ 0.00$Patient-Centered Medical Home (PCMH) Payments 8,301,752$ 2,834,638 38,926 2.93$ 9.50$Subtotal (Covered Services) 304,418,646$ 5,360,861 348.36$

Capitation — PACE -$ - - -$ -$Dental 206,170$ 6,291 86 32.77$ 0.24$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) 458,466$ 16,076 221 28.52$ 0.52$Subtotal (Excluded Services) 664,636$ 22,367 0.76$Total (All) 305,083,282$ 5,383,228 349.12$



SFY 2016

Statewide

Standard Plan


Non-Duals

Newborn (<1)

873,86172,822




55 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 45,623,534$ 39,970 46 1,141.44$ 4.35$Inpatient — BH (LME/MCO) 9,084,475$ 14,407 16 630.55$ 0.87$Outpatient Hospital 94,880,340$ 373,939 428 253.73$ 9.04$Emergency Room 147,141,987$ 508,318 581 289.47$ 14.02$Physician 205,038,456$ 2,813,437 3,216 72.88$ 19.53$FQHC/RHC 17,984,367$ 164,620 188 109.25$ 1.71$Other Clinic 63,068,341$ 605,989 693 104.07$ 6.01$Other Practitioner 1,336,185$ 17,698 20 75.50$ 0.13$Therapies 43,076,628$ 387,394 443 111.20$ 4.10$Prescribed Drugs 353,810,116$ 3,870,655 4,425 91.41$ 33.71$Enhanced BH 59,193,429$ 793,856 908 74.56$ 5.64$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 12,910$ 68 0 189.21$ 0.00$LTSS – State Plan Home and Community Based Services (HCBS) 2,201,163$ 313,792 359 7.01$ 0.21$LTSS – HCBS Waiver Services 665$ 59 0 11.21$ 0.00$Durable Medical Equipment 17,470,892$ 5,949,637 6,802 2.94$ 1.66$Lab and X-Ray 14,945,410$ 868,648 993 17.21$ 1.42$Optical 15,653,871$ 774,423 885 20.21$ 1.49$Limited Dental Services 4,443,344$ 178,368 204 24.91$ 0.42$Transportation 6,120,853$ 242,206 277 25.27$ 0.58$Case Management 2,722$ 210 0 12.96$ 0.00$Patient-Centered Medical Home (PCMH) Payments 82,757,567$ 32,171,159 36,779 2.57$ 7.88$Subtotal (Covered Services) 1,183,847,255$ 50,088,853 112.79$

Capitation — PACE 478,497$ 10,785 12 44.37$ 0.05$Dental 199,231,919$ 4,620,039 5,282 43.12$ 18.98$Local Education Agency (LEA) 8,566,674$ 266,969 305 32.09$ 0.82$Children’s Developmental Services Agencies (CDSA) 971,200$ 34,392 39 28.24$ 0.09$Subtotal (Excluded Services) 209,248,291$ 4,932,185 19.94$Total (All) 1,393,095,546$ 55,021,038 132.72$



SFY 2016

Statewide

Standard Plan


Non-Duals

Child (1-20)

10,496,478874,707




56 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 73,744,909$ 68,914 295 1,070.11$ 26.28$Inpatient — BH (LME/MCO) 5,328,898$ 8,125 35 655.84$ 1.90$Outpatient Hospital 107,451,186$ 379,054 1,621 283.47$ 38.29$Emergency Room 146,377,592$ 347,440 1,486 421.30$ 52.16$Physician 157,873,719$ 1,397,249 5,975 112.99$ 56.26$FQHC/RHC 10,282,616$ 92,988 398 110.58$ 3.66$Other Clinic 27,309,114$ 154,818 662 176.39$ 9.73$Other Practitioner 1,159,442$ 17,453 75 66.43$ 0.41$Therapies 6,922$ 131 1 52.68$ 0.00$Prescribed Drugs 261,942,140$ 3,127,250 13,373 83.76$ 93.34$Enhanced BH 20,922,070$ 320,155 1,369 65.35$ 7.46$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 268,844$ 1,788 8 150.35$ 0.10$LTSS – State Plan Home and Community Based Services (HCBS) 5,567,693$ 1,048,343 4,483 5.31$ 1.98$LTSS – HCBS Waiver Services 19,679$ 4,581 20 4.30$ 0.01$Durable Medical Equipment 14,409,540$ 6,119,316 26,167 2.35$ 5.13$Lab and X-Ray 40,293,585$ 1,971,835 8,432 20.43$ 14.36$Optical 1,062,863$ 16,197 69 65.62$ 0.38$Limited Dental Services 142$ 7 0 20.34$ 0.00$Transportation 8,398,572$ 197,316 844 42.56$ 2.99$Case Management 85,517$ 6,619 28 12.92$ 0.03$Patient-Centered Medical Home (PCMH) Payments 23,811,833$ 5,982,922 25,584 3.98$ 8.49$Subtotal (Covered Services) 906,316,876$ 21,262,502 322.96$

Capitation — PACE 373,378$ 7,370 32 50.66$ 0.13$Dental 48,403,860$ 758,884 3,245 63.78$ 17.25$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 48,777,238$ 766,254 17.38$Total (All) 955,094,114$ 22,028,756 340.35$



SFY 2016

Statewide

Standard Plan


Non-Duals

Adult (21+)

2,806,250233,854




57 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,835,385$ 4,287 49 1,127.79$ 4.57$Inpatient — BH (LME/MCO) -$ - - -$ -$Outpatient Hospital 10,460,906$ 37,015 420 282.61$ 9.89$Emergency Room 9,686,208$ 28,437 323 340.62$ 9.16$Physician 26,297,303$ 296,789 3,367 88.61$ 24.86$FQHC/RHC 1,485,476$ 13,145 149 113.01$ 1.40$Other Clinic 4,806,257$ 41,633 472 115.44$ 4.54$Other Practitioner 226,845$ 3,283 37 69.10$ 0.21$Therapies 1,370,837$ 13,550 154 101.17$ 1.30$Prescribed Drugs 49,169,484$ 408,805 4,638 120.28$ 46.49$Enhanced BH 4,120,608$ 51,570 585 79.90$ 3.90$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 143,617$ 7,126 81 20.15$ 0.14$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 3,097,498$ 958,364 10,873 3.23$ 2.93$Lab and X-Ray 1,038,361$ 70,901 804 14.65$ 0.98$Optical 2,302,823$ 112,513 1,277 20.47$ 2.18$Limited Dental Services 262$ 4 0 65.51$ 0.00$Transportation 178,531$ 11,020 125 16.20$ 0.17$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 5,973,402$ 1,787,895 20,285 3.34$ 5.65$Subtotal (Covered Services) 125,193,804$ 3,846,337 118.37$

Capitation — PACE 822$ 2 0 411.01$ 0.00$Dental 20,327,757$ 531,827 6,034 38.22$ 19.22$Local Education Agency (LEA) 464$ 19 0 24.40$ 0.00$Children’s Developmental Services Agencies (CDSA) 619$ 10 0 61.89$ 0.00$Subtotal (Excluded Services) 20,329,662$ 531,858 19.22$Total (All) 145,523,466$ 4,378,195 137.59$



SFY 2016

Statewide

Standard Plan

NC Health Choice

Non-Duals

All Ages

1,057,65988,138




58 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 6,406,348$ 6,604 59 970.14$ 4.81$Inpatient — BH (LME/MCO) 908,218$ 1,431 13 634.62$ 0.68$Outpatient Hospital 11,864,661$ 47,000 423 252.44$ 8.90$Emergency Room 13,872,535$ 48,240 434 287.58$ 10.41$Physician 27,901,883$ 394,877 3,556 70.66$ 20.94$FQHC/RHC 2,048,452$ 18,851 170 108.67$ 1.54$Other Clinic 7,832,131$ 78,369 706 99.94$ 5.88$Other Practitioner 204,268$ 2,856 26 71.52$ 0.15$Therapies 6,193,734$ 55,897 503 110.81$ 4.65$Prescribed Drugs 45,189,429$ 475,404 4,281 95.05$ 33.91$Enhanced BH 5,385,230$ 73,470 662 73.30$ 4.04$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 238,300$ 25,719 232 9.27$ 0.18$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 2,458,951$ 720,934 6,492 3.41$ 1.85$Lab and X-Ray 1,309,174$ 85,935 774 15.23$ 0.98$Optical 2,107,907$ 102,991 927 20.47$ 1.58$Limited Dental Services 502,015$ 20,225 182 24.82$ 0.38$Transportation 425,927$ 20,799 187 20.48$ 0.32$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 10,451,018$ 4,050,589 36,478 2.58$ 7.84$Subtotal (Covered Services) 145,300,182$ 6,230,191 109.04$

Capitation — PACE 69,485$ 1,555 14 44.68$ 0.05$Dental 25,979,777$ 621,301 5,595 41.82$ 19.50$Local Education Agency (LEA) 1,132,799$ 34,922 314 32.44$ 0.85$Children’s Developmental Services Agencies (CDSA) 115,534$ 4,155 37 27.81$ 0.09$Subtotal (Excluded Services) 27,297,595$ 661,932 20.49$Total (All) 172,597,778$ 6,892,123 129.53$



SFY 2016

Statewide

Standard Plan

M-CHIP

Non-Duals

All Ages

1,332,508111,042




59 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 99,131,651$ 138,635 31,979 715.06$ 1,905.54$Inpatient — BH (LME/MCO) 43,901$ 66 15 662.93$ 0.84$Outpatient Hospital 4,338,711$ 37,017 8,539 117.21$ 83.40$Emergency Room 2,722,881$ 10,173 2,347 267.67$ 52.34$Physician 62,000,207$ 137,972 31,826 449.37$ 1,191.78$FQHC/RHC 881,536$ 4,118 950 214.05$ 16.95$Other Clinic 4,478,875$ 18,088 4,172 247.62$ 86.09$Other Practitioner 10,004$ 287 66 34.82$ 0.19$Therapies 193$ 3 1 64.38$ 0.00$Prescribed Drugs 2,555,143$ 77,302 17,831 33.05$ 49.12$Enhanced BH 177,624$ 2,988 689 59.44$ 3.41$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 801$ 5 1 160.01$ 0.02$LTSS – State Plan Home and Community Based Services (HCBS) 55,270$ 12,130 2,798 4.56$ 1.06$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 254,985$ 197,178 45,482 1.29$ 4.90$Lab and X-Ray 910,260$ 43,209 9,967 21.07$ 17.50$Optical 13,714$ 555 128 24.70$ 0.26$Limited Dental Services -$ - - -$ -$Transportation 531,241$ 39,439 9,097 13.47$ 10.21$Case Management 2,280$ 176 41 12.95$ 0.04$Patient-Centered Medical Home (PCMH) Payments 551,892$ 125,752 29,007 4.39$ 10.61$Subtotal (Covered Services) 178,661,170$ 845,094 3,434.27$

Capitation — PACE 10,168$ 436 101 23.32$ 0.20$Dental 289,030$ 4,677 1,079 61.79$ 5.56$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 299,198$ 5,114 5.75$Total (All) 178,960,367$ 850,208 3,440.02$



SFY 2016

Statewide

Standard Plan

Delivery Episode

Non-Duals

All Ages

52,0234,335




60 of 179



61 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,980,520$ 4,836 215 1,029.79$ 18.42$Inpatient — BH (LME/MCO) 10,182,319$ 14,171 629 718.54$ 37.66$Outpatient Hospital 4,725,905$ 18,055 801 261.74$ 17.48$Emergency Room 4,579,305$ 13,767 611 332.63$ 16.94$Physician 8,748,325$ 108,241 4,804 80.82$ 32.35$FQHC/RHC 597,300$ 5,061 225 118.03$ 2.21$Other Clinic 2,342,739$ 21,970 975 106.63$ 8.66$Other Practitioner 49,929$ 708 31 70.54$ 0.18$Therapies 4,915,908$ 43,713 1,940 112.46$ 18.18$Prescribed Drugs 39,013,211$ 279,722 12,414 139.47$ 144.28$Enhanced BH 116,291,772$ 1,013,686 44,986 114.72$ 430.07$B3 Services 385,764$ 62,412 2,770 6.18$ 1.43$LTSS – ICF/IID and Nursing Home 1,701,447$ 24,262 1,077 70.13$ 6.29$LTSS – State Plan Home and Community Based Services (HCBS) 838,585$ 127,094 5,640 6.60$ 3.10$LTSS – HCBS Waiver Services 1,448,670$ 207,310 9,200 6.99$ 5.36$Durable Medical Equipment 2,110,942$ 928,201 41,192 2.27$ 7.81$Lab and X-Ray 1,093,583$ 56,881 2,524 19.23$ 4.04$Optical 595,374$ 28,458 1,263 20.92$ 2.20$Limited Dental Services 112,349$ 4,498 200 24.98$ 0.42$Transportation 663,183$ 10,499 466 63.16$ 2.45$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,957,927$ 784,728 34,825 2.50$ 7.24$Subtotal (Covered Services) 207,335,058$ 3,758,273 766.77$




SFY 2016

Statewide



Non-Duals

All Ages

270,40222,534




62 of 179



63 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 49,924,090$ 51,974 1,335 960.55$ 106.90$Inpatient — BH (LME/MCO) 14,024,818$ 18,947 487 740.21$ 30.03$Outpatient Hospital 27,885,992$ 77,823 2,000 358.32$ 59.71$Emergency Room 12,779,142$ 39,597 1,017 322.73$ 27.36$Physician 37,275,761$ 322,179 8,278 115.70$ 79.82$FQHC/RHC 1,130,905$ 9,533 245 118.63$ 2.42$Other Clinic 4,128,381$ 40,122 1,031 102.90$ 8.84$Other Practitioner 105,270$ 1,745 45 60.34$ 0.23$Therapies 42,793,361$ 373,925 9,608 114.44$ 91.63$Prescribed Drugs 111,848,116$ 657,803 16,902 170.03$ 239.50$Enhanced BH 98,484,607$ 1,403,952 36,075 70.15$ 210.88$B3 Services 8,049,471$ 1,352,420 34,751 5.95$ 17.24$LTSS – ICF/IID and Nursing Home 42,382,786$ 226,805 5,828 186.87$ 90.75$LTSS – State Plan Home and Community Based Services (HCBS) 29,405,002$ 4,796,359 123,244 6.13$ 62.96$LTSS – HCBS Waiver Services 109,051,494$ 20,525,028 527,396 5.31$ 233.51$Durable Medical Equipment 31,275,340$ 13,332,543 342,583 2.35$ 66.97$Lab and X-Ray 1,799,379$ 87,790 2,256 20.50$ 3.85$Optical 711,535$ 39,236 1,008 18.13$ 1.52$Limited Dental Services 403,780$ 16,216 417 24.90$ 0.86$Transportation 1,937,134$ 98,419 2,529 19.68$ 4.15$Case Management 7,544$ 582 15 12.96$ 0.02$Patient-Centered Medical Home (PCMH) Payments 5,190,987$ 1,409,899 36,228 3.68$ 11.12$Subtotal (Covered Services) 630,594,893$ 44,882,896 1,350.28$




SFY 2016

Statewide


Default – I/DD

Non-Duals

Child (<21)

467,01238,918




64 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 21,394,257$ 27,088 1,740 789.79$ 114.53$Inpatient — BH (LME/MCO) 14,234,622$ 20,733 1,332 686.56$ 76.20$Outpatient Hospital 11,160,012$ 36,956 2,374 301.98$ 59.74$Emergency Room 16,533,688$ 36,460 2,342 453.47$ 88.51$Physician 17,988,364$ 153,310 9,848 117.33$ 96.30$FQHC/RHC 1,084,014$ 9,727 625 111.44$ 5.80$Other Clinic 2,002,597$ 5,189 333 385.92$ 10.72$Other Practitioner 202,650$ 2,915 187 69.52$ 1.08$Therapies 1,120$ 18 1 62.05$ 0.01$Prescribed Drugs 99,057,710$ 751,210 48,257 131.86$ 530.28$Enhanced BH 30,016,213$ 2,763,804 177,542 10.86$ 160.68$B3 Services 28,763,178$ 2,631,347 169,034 10.93$ 153.98$LTSS – ICF/IID and Nursing Home 128,699,737$ 637,101 40,926 202.01$ 688.96$LTSS – State Plan Home and Community Based Services (HCBS) 30,671,637$ 7,215,924 463,540 4.25$ 164.19$LTSS – HCBS Waiver Services 226,943,055$ 34,461,215 2,213,735 6.59$ 1,214.87$Durable Medical Equipment 10,807,688$ 6,401,581 411,228 1.69$ 57.86$Lab and X-Ray 4,750,076$ 244,627 15,714 19.42$ 25.43$Optical 180,313$ 2,678 172 67.33$ 0.97$Limited Dental Services 478$ 17 1 28.11$ 0.00$Transportation 5,047,812$ 192,215 12,348 26.26$ 27.02$Case Management 57,454$ 4,459 286 12.88$ 0.31$Patient-Centered Medical Home (PCMH) Payments 2,503,259$ 366,398 23,537 6.83$ 13.40$Subtotal (Covered Services) 652,099,934$ 55,964,974 3,490.82$

Capitation — PACE 411,181$ 368 24 1,117.23$ 2.20$Dental 3,326,098$ 55,977 3,596 59.42$ 17.81$Local Education Agency (LEA) 90$ 4 0 22.53$ 0.00$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 3,737,369$ 56,349 20.01$Total (All) 655,837,302$ 56,021,323 3,510.83$



SFY 2016

Statewide


Default – I/DD

Non-Duals

Adult (21+)

186,80415,567




65 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,337,010$ 8,296 394 161.17$ 5.29$Inpatient — BH (LME/MCO) 4,995,315$ 15,329 728 325.87$ 19.76$Outpatient Hospital 2,637,101$ 29,586 1,404 89.13$ 10.43$Emergency Room 2,780,493$ 33,132 1,573 83.92$ 11.00$Physician 4,465,711$ 223,733 10,619 19.96$ 17.66$FQHC/RHC 206,921$ 7,743 368 26.72$ 0.82$Other Clinic 333,416$ 2,730 130 122.13$ 1.32$Other Practitioner 70,159$ 6,054 287 11.59$ 0.28$Therapies 33,566$ 312 15 107.45$ 0.13$Prescribed Drugs 7,100,742$ 83,872 3,981 84.66$ 28.09$Enhanced BH 27,191,220$ 3,733,221 177,197 7.28$ 107.55$B3 Services 25,704,738$ 2,410,576 114,418 10.66$ 101.67$LTSS – ICF/IID and Nursing Home 296,671,366$ 1,296,812 61,553 228.77$ 1,173.46$LTSS – State Plan Home and Community Based Services (HCBS) 69,804,826$ 19,098,356 906,503 3.66$ 276.11$LTSS – HCBS Waiver Services 284,958,741$ 37,736,723 1,791,173 7.55$ 1,127.13$Durable Medical Equipment 6,875,917$ 7,554,345 358,567 0.91$ 27.20$Lab and X-Ray 141,997$ 12,496 593 11.36$ 0.56$Optical 80,680$ 5,795 275 13.92$ 0.32$Limited Dental Services 100$ 4 0 25.02$ 0.00$Transportation 9,235,153$ 272,988 12,957 33.83$ 36.53$Case Management 43,062$ 3,328 158 12.94$ 0.17$Patient-Centered Medical Home (PCMH) Payments 2,625,352$ 358,418 17,012 7.32$ 10.38$Subtotal (Covered Services) 747,293,585$ 72,893,849 2,955.86$

Capitation — PACE 2,317,698$ 1,056 50 2,194.56$ 9.17$Dental 3,799,592$ 66,613 3,162 57.04$ 15.03$Local Education Agency (LEA) 10,580$ 361 17 29.30$ 0.04$Children’s Developmental Services Agencies (CDSA) 307$ 13 1 23.61$ 0.00$Subtotal (Excluded Services) 6,128,177$ 68,043 24.24$Total (All) 753,421,761$ 72,961,892 2,980.10$



SFY 2016

Statewide


Default – I/DD

Duals

All Ages

252,81821,068




66 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,103,241$ 5,171 378 986.92$ 31.07$Inpatient — BH (LME/MCO) 22,409,680$ 33,001 2,411 679.06$ 136.46$Outpatient Hospital 2,361,051$ 11,013 805 214.39$ 14.38$Emergency Room 7,761,317$ 21,484 1,570 361.26$ 47.26$Physician 5,535,083$ 63,618 4,649 87.01$ 33.70$FQHC/RHC 487,300$ 4,201 307 116.00$ 2.97$Other Clinic 1,110,895$ 9,312 680 119.30$ 6.76$Other Practitioner 31,927$ 388 28 82.39$ 0.19$Therapies 645,243$ 6,007 439 107.42$ 3.93$Prescribed Drugs 32,649,584$ 228,119 16,669 143.13$ 198.81$Enhanced BH 206,965,609$ 1,962,044 143,368 105.48$ 1,260.26$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 259,286$ 47,482 3,470 5.46$ 1.58$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 614,719$ 299,540 21,888 2.05$ 3.74$Lab and X-Ray 2,186,165$ 108,414 7,922 20.16$ 13.31$Optical 378,797$ 19,033 1,391 19.90$ 2.31$Limited Dental Services 797$ 32 2 24.90$ 0.00$Transportation 460,939$ 32,732 2,392 14.08$ 2.81$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,413,293$ 477,895 34,920 2.96$ 8.61$Subtotal (Covered Services) 290,374,927$ 3,329,483 1,768.16$

Capitation — PACE 32,854$ 248 18 132.46$ 0.20$Dental 3,399,488$ 72,901 5,327 46.63$ 20.70$Local Education Agency (LEA) 225,972$ 6,539 478 34.56$ 1.38$Children’s Developmental Services Agencies (CDSA) 27,508$ 1,451 106 18.96$ 0.17$Subtotal (Excluded Services) 3,685,821$ 81,139 22.44$Total (All) 294,060,747$ 3,410,623 1,790.61$



SFY 2016

Statewide



Non-Duals

Child (<21)

164,22413,685




67 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 12,309,968$ 14,060 1,535 875.54$ 111.99$Inpatient — BH (LME/MCO) 11,682,133$ 17,580 1,919 664.53$ 106.28$Outpatient Hospital 6,040,818$ 21,647 2,363 279.05$ 54.96$Emergency Room 17,664,188$ 39,269 4,287 449.82$ 160.70$Physician 13,081,172$ 99,756 10,891 131.13$ 119.01$FQHC/RHC 967,263$ 8,265 902 117.04$ 8.80$Other Clinic 877,680$ 4,930 538 178.02$ 7.98$Other Practitioner 96,062$ 1,292 141 74.36$ 0.87$Therapies 690$ 12 1 57.39$ 0.01$Prescribed Drugs 55,204,943$ 391,907 42,786 140.86$ 502.24$Enhanced BH 58,891,541$ 3,658,894 399,453 16.10$ 535.78$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 86,271$ 553 60 155.91$ 0.78$LTSS – State Plan Home and Community Based Services (HCBS) 5,276,506$ 1,379,159 150,567 3.83$ 48.00$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 2,345,046$ 790,526 86,304 2.97$ 21.33$Lab and X-Ray 11,282,241$ 515,215 56,248 21.90$ 102.64$Optical 66,943$ 1,022 112 65.47$ 0.61$Limited Dental Services -$ - - -$ -$Transportation 2,417,964$ 163,133 17,810 14.82$ 22.00$Case Management 91,216$ 7,116 777 12.82$ 0.83$Patient-Centered Medical Home (PCMH) Payments 1,306,400$ 229,542 25,060 5.69$ 11.89$Subtotal (Covered Services) 199,689,045$ 7,343,879 1,816.73$




SFY 2016

Statewide



Non-Duals

Adult (21+)

109,9179,160




68 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 472,258$ 1,436 304 328.96$ 8.34$Inpatient — BH (LME/MCO) 931,343$ 5,341 1,132 174.36$ 16.46$Outpatient Hospital 706,541$ 8,249 1,749 85.65$ 12.48$Emergency Room 1,275,712$ 13,919 2,951 91.65$ 22.54$Physician 1,063,084$ 48,654 10,316 21.85$ 18.78$FQHC/RHC 81,391$ 2,896 614 28.10$ 1.44$Other Clinic 84,507$ 794 168 106.42$ 1.49$Other Practitioner 14,374$ 1,055 224 13.63$ 0.25$Therapies -$ - - -$ -$Prescribed Drugs 2,544,759$ 22,051 4,675 115.40$ 44.96$Enhanced BH 37,173,692$ 3,685,560 781,405 10.09$ 656.79$B3 Services 97$ 8 2 12.00$ 0.00$LTSS – ICF/IID and Nursing Home 29,543$ 612 130 48.23$ 0.52$LTSS – State Plan Home and Community Based Services (HCBS) 7,499,671$ 2,105,185 446,337 3.56$ 132.51$LTSS – HCBS Waiver Services 3,600$ 983 208 3.66$ 0.06$Durable Medical Equipment 521,661$ 321,072 68,073 1.62$ 9.22$Lab and X-Ray 174,599$ 9,142 1,938 19.10$ 3.08$Optical 14,002$ 895 190 15.64$ 0.25$Limited Dental Services -$ - - -$ -$Transportation 1,091,619$ 107,334 22,757 10.17$ 19.29$Case Management 39,599$ 3,063 649 12.93$ 0.70$Patient-Centered Medical Home (PCMH) Payments 667,521$ 91,785 19,460 7.27$ 11.79$Subtotal (Covered Services) 54,389,573$ 6,430,037 960.96$




SFY 2016

Statewide



Duals

All Ages

56,5994,717




69 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 258,795$ 211 290 1,225.78$ 29.66$Inpatient — BH (LME/MCO) 148,208$ 191 262 777.01$ 16.99$Outpatient Hospital 92,123$ 494 680 186.38$ 10.56$Emergency Room 430,935$ 1,126 1,549 382.72$ 49.40$Physician 302,284$ 2,571 3,537 117.55$ 34.65$FQHC/RHC 25,380$ 216 297 117.35$ 2.91$Other Clinic 67,431$ 461 634 146.37$ 7.73$Other Practitioner 1,141$ 16 22 71.18$ 0.13$Therapies 6,893$ 70 96 98.31$ 0.79$Prescribed Drugs 403,186$ 4,129 5,680 97.65$ 46.22$Enhanced BH 2,754,951$ 46,274 63,651 59.54$ 315.79$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home -$ - - -$ -$LTSS – State Plan Home and Community Based Services (HCBS) 1,493$ 59 81 25.31$ 0.17$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 7,787$ 4,023 5,534 1.94$ 0.89$Lab and X-Ray 876,050$ 38,875 53,474 22.53$ 100.42$Optical 11,219$ 532 732 21.08$ 1.29$Limited Dental Services -$ - - -$ -$Transportation 26,181$ 643 884 40.74$ 3.00$Case Management 2,061$ 159 219 12.96$ 0.24$Patient-Centered Medical Home (PCMH) Payments 76,143$ 26,328 36,215 2.89$ 8.73$Subtotal (Covered Services) 5,492,259$ 126,379 629.56$

Capitation — PACE 422$ 11 15 38.38$ 0.05$Dental 163,081$ 2,734 3,761 59.64$ 18.69$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) 351$ 18 25 19.49$ 0.04$Subtotal (Excluded Services) 163,854$ 2,763 18.78$Total (All) 5,656,114$ 129,143 648.34$



SFY 2016

Statewide


Default – SUD

Non-Duals

Child (<21)

8,724727




70 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 8,254,247$ 8,183 1,252 1,008.69$ 105.22$Inpatient — BH (LME/MCO) 457,387$ 731 112 625.63$ 5.83$Outpatient Hospital 3,100,782$ 10,018 1,532 309.52$ 39.53$Emergency Room 6,517,950$ 14,580 2,230 447.05$ 83.09$Physician 8,494,667$ 54,688 8,365 155.33$ 108.28$FQHC/RHC 391,671$ 3,234 495 121.13$ 4.99$Other Clinic 981,981$ 6,407 980 153.27$ 12.52$Other Practitioner 32,814$ 399 61 82.34$ 0.42$Therapies 236$ 4 1 58.78$ 0.00$Prescribed Drugs 15,606,496$ 122,311 18,710 127.60$ 198.94$Enhanced BH 26,499,792$ 851,714 130,285 31.11$ 337.80$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 35,846$ 241 37 148.64$ 0.46$LTSS – State Plan Home and Community Based Services (HCBS) 1,783,760$ 426,402 65,226 4.18$ 22.74$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 899,624$ 283,825 43,416 3.17$ 11.47$Lab and X-Ray 14,989,025$ 604,207 92,424 24.81$ 191.07$Optical 29,120$ 441 67 66.01$ 0.37$Limited Dental Services -$ - - -$ -$Transportation 755,712$ 30,961 4,736 24.41$ 9.63$Case Management 33,729$ 2,606 399 12.94$ 0.43$Patient-Centered Medical Home (PCMH) Payments 763,120$ 168,201 25,729 4.54$ 9.73$Subtotal (Covered Services) 89,627,958$ 2,589,152 1,142.51$




SFY 2016

Statewide


Default – SUD

Non-Duals

Adult (21+)

78,4486,537




71 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 58,552$ 157 123 373.16$ 3.82$Inpatient — BH (LME/MCO) 7,232$ 28 22 258.12$ 0.47$Outpatient Hospital 136,186$ 1,928 1,509 70.63$ 8.88$Emergency Room 254,908$ 2,849 2,230 89.48$ 16.63$Physician 277,490$ 12,497 9,781 22.20$ 18.10$FQHC/RHC 19,115$ 665 520 28.75$ 1.25$Other Clinic 33,481$ 414 324 80.95$ 2.18$Other Practitioner 2,983$ 157 123 18.97$ 0.19$Therapies -$ - - -$ -$Prescribed Drugs 140,122$ 2,489 1,948 56.30$ 9.14$Enhanced BH 5,757,895$ 147,994 115,831 38.91$ 375.55$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 944$ 187 146 5.04$ 0.06$LTSS – State Plan Home and Community Based Services (HCBS) 1,462,763$ 413,537 323,666 3.54$ 95.41$LTSS – HCBS Waiver Services -$ - - -$ -$Durable Medical Equipment 76,891$ 52,310 40,942 1.47$ 5.02$Lab and X-Ray 63,255$ 3,220 2,521 19.64$ 4.13$Optical 3,630$ 317 248 11.45$ 0.24$Limited Dental Services -$ - - -$ -$Transportation 169,095$ 16,284 12,745 10.38$ 11.03$Case Management 34,903$ 2,699 2,113 12.93$ 2.28$Patient-Centered Medical Home (PCMH) Payments 178,491$ 24,339 19,050 7.33$ 11.64$Subtotal (Covered Services) 8,677,936$ 682,072 566.00$

Capitation — PACE 10,324$ 45 35 229.39$ 0.67$Dental 278,959$ 4,016 3,144 69.45$ 18.19$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 289,283$ 4,061 18.87$Total (All) 8,967,219$ 686,133 584.87$



SFY 2016

Statewide


Default – SUD

Duals

All Ages

15,3321,278




72 of 179



73 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 6,919,933$ 5,897 2,862 1,173.46$ 279.83$Inpatient — BH (LME/MCO) 12,435$ 11 5 1,106.34$ 0.50$Outpatient Hospital 4,208,147$ 12,218 5,929 344.43$ 170.17$Emergency Room 955,343$ 2,190 1,063 436.25$ 38.63$Physician 3,501,301$ 28,955 14,051 120.92$ 141.59$FQHC/RHC 26,959$ 229 111 117.54$ 1.09$Other Clinic 120,490$ 1,102 535 109.38$ 4.87$Other Practitioner 7,015$ 126 61 55.58$ 0.28$Therapies 4,873,241$ 40,288 19,550 120.96$ 197.07$Prescribed Drugs 21,239,840$ 85,962 41,714 247.08$ 858.90$Enhanced BH 357,716$ 10,595 5,141 33.76$ 14.47$B3 Services 131,267$ 29,875 14,497 4.39$ 5.31$LTSS – ICF/IID and Nursing Home 433,370$ 1,157 561 374.61$ 17.52$LTSS – State Plan Home and Community Based Services (HCBS) 6,218,462$ 901,153 437,294 6.90$ 251.46$LTSS – HCBS Waiver Services 92,011,862$ 15,171,927 7,362,332 6.06$ 3,720.81$Durable Medical Equipment 19,961,215$ 6,762,240 3,281,446 2.95$ 807.20$Lab and X-Ray 36,045$ 2,292 1,112 15.73$ 1.46$Optical 25,515$ 1,889 917 13.51$ 1.03$Limited Dental Services 3,786$ 151 73 25.06$ 0.15$Transportation 433,800$ 25,747 12,494 16.85$ 17.54$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 328,306$ 65,219 31,648 5.03$ 13.28$Subtotal (Covered Services) 161,806,048$ 23,149,222 6,543.17$




SFY 2016

Statewide


CAP/C

Non-Duals

All Ages

24,7292,061




74 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 6,089,329$ 6,965 4,206 874.33$ 306.46$Inpatient — BH (LME/MCO) 197,199$ 264 159 747.33$ 9.92$Outpatient Hospital 2,868,640$ 7,711 4,657 372.02$ 144.37$Emergency Room 2,136,195$ 3,781 2,284 564.96$ 107.51$Physician 3,862,205$ 28,805 17,396 134.08$ 194.37$FQHC/RHC 161,778$ 1,453 878 111.33$ 8.14$Other Clinic 387,424$ 433 261 895.60$ 19.50$Other Practitioner 40,320$ 611 369 66.00$ 2.03$Therapies 2,148$ 21 13 102.14$ 0.11$Prescribed Drugs 20,952,519$ 152,012 91,804 137.83$ 1,054.48$Enhanced BH 602,318$ 16,257 9,818 37.05$ 30.31$B3 Services 402,044$ 63,434 38,310 6.34$ 20.23$LTSS – ICF/IID and Nursing Home 324,393$ 1,459 881 222.35$ 16.33$LTSS – State Plan Home and Community Based Services (HCBS) 4,689,870$ 947,427 572,175 4.95$ 236.03$LTSS – HCBS Waiver Services 37,298,716$ 11,471,139 6,927,714 3.25$ 1,877.14$Durable Medical Equipment 5,054,471$ 1,632,523 985,923 3.10$ 254.38$Lab and X-Ray 333,685$ 19,100 11,535 17.47$ 16.79$Optical 28,252$ 439 265 64.33$ 1.42$Limited Dental Services 0$ 1 1 0.26$ 0.00$Transportation 1,573,964$ 49,197 29,712 31.99$ 79.21$Case Management 2,994$ 231 140 12.96$ 0.15$Patient-Centered Medical Home (PCMH) Payments 281,461$ 38,271 23,113 7.35$ 14.17$Subtotal (Covered Services) 87,289,925$ 14,441,534 4,393.05$

Capitation — PACE 20,656$ 60 36 344.22$ 1.04$Dental 281,293$ 4,168 2,517 67.48$ 14.16$Local Education Agency (LEA) 1,346$ 70 42 19.23$ 0.07$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 303,295$ 4,298 15.26$Total (All) 87,593,221$ 14,445,833 4,408.32$



SFY 2016

Statewide


CAP/DA

Non-Duals

All Ages

19,8701,656




75 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 13,903,853$ 16,322 9,555 851.83$ 678.27$Inpatient — BH (LME/MCO) 295,819$ 484 283 611.62$ 14.43$Outpatient Hospital 2,800,553$ 10,071 5,895 278.09$ 136.62$Emergency Room 2,339,157$ 4,172 2,442 560.73$ 114.11$Physician 6,984,653$ 56,785 33,242 123.00$ 340.73$FQHC/RHC 97,540$ 951 556 102.61$ 4.76$Other Clinic 1,239,252$ 599 351 2,069.16$ 60.45$Other Practitioner 53,997$ 700 410 77.13$ 2.63$Therapies -$ - - -$ -$Prescribed Drugs 17,219,988$ 201,330 117,857 85.53$ 840.04$Enhanced BH 556,989$ 15,326 8,972 36.34$ 27.17$B3 Services 118,979$ 8,381 4,906 14.20$ 5.80$LTSS – ICF/IID and Nursing Home 84,090,967$ 486,663 284,890 172.79$ 4,102.20$LTSS – State Plan Home and Community Based Services (HCBS) 2,495,839$ 213,889 125,209 11.67$ 121.75$LTSS – HCBS Waiver Services 217,772$ 38,476 22,524 5.66$ 10.62$Durable Medical Equipment 1,024,057$ 174,188 101,968 5.88$ 49.96$Lab and X-Ray 572,668$ 40,837 23,905 14.02$ 27.94$Optical 60,719$ 927 543 65.47$ 2.96$Limited Dental Services 15$ 1 1 15.25$ 0.00$Transportation 1,113,865$ 93,862 54,946 11.87$ 54.34$Case Management 467$ 36 21 12.96$ 0.02$Patient-Centered Medical Home (PCMH) Payments 75,754$ 10,493 6,143 7.22$ 3.70$Subtotal (Covered Services) 135,262,903$ 1,374,491 6,598.51$

Capitation — PACE 21,242$ 73 43 290.96$ 1.04$Dental 370,375$ 5,033 2,946 73.60$ 18.07$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 391,617$ 5,106 19.10$Total (All) 135,654,521$ 1,379,597 6,617.62$



SFY 2016

Statewide


Long-Term Nursing Facility

Non-Duals

All Ages

20,4991,708




76 of 179



77 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 16,086,225$ 164,172 864 97.98$ 7.05$Inpatient — BH (LME/MCO) 1,444,161$ 7,436 39 194.22$ 0.63$Outpatient Hospital 30,734,369$ 386,381 2,033 79.54$ 13.47$Emergency Room 22,728,050$ 239,433 1,260 94.92$ 9.96$Physician 45,940,607$ 2,103,721 11,068 21.84$ 20.14$FQHC/RHC 2,338,306$ 95,625 503 24.45$ 1.03$Other Clinic 6,149,749$ 51,895 273 118.50$ 2.70$Other Practitioner 563,647$ 48,054 253 11.73$ 0.25$Therapies 10,093$ 170 1 59.22$ 0.00$Prescribed Drugs 43,737,828$ 473,468 2,491 92.38$ 19.18$Enhanced BH 6,671,218$ 486,441 2,559 13.71$ 2.92$B3 Services 15,539$ 1,295 7 12.00$ 0.01$LTSS – ICF/IID and Nursing Home 5,319,354$ 139,089 732 38.24$ 2.33$LTSS – State Plan Home and Community Based Services (HCBS) 320,144,010$ 86,747,944 456,379 3.69$ 140.36$LTSS – HCBS Waiver Services 228,761$ 60,212 317 3.80$ 0.10$Durable Medical Equipment 27,004,602$ 22,037,324 115,938 1.23$ 11.84$Lab and X-Ray 1,276,858$ 102,059 537 12.51$ 0.56$Optical 828,010$ 80,921 426 10.23$ 0.36$Limited Dental Services 100$ 4 0 24.90$ 0.00$Transportation 20,817,016$ 1,182,148 6,219 17.61$ 9.13$Case Management 588,334$ 45,519 239 12.93$ 0.26$Patient-Centered Medical Home (PCMH) Payments 23,884,218$ 3,196,989 16,819 7.47$ 10.47$Subtotal (Covered Services) 576,511,053$ 117,650,299 252.75$

Capitation — PACE 28,580,813$ 13,739 72 2,080.22$ 12.53$Dental 29,416,414$ 442,667 2,329 66.45$ 12.90$Local Education Agency (LEA) 167$ 7 0 23.88$ 0.00$Children’s Developmental Services Agencies (CDSA) 2,902$ 112 1 25.91$ 0.00$Subtotal (Excluded Services) 58,000,296$ 456,526 25.43$Total (All) 634,511,350$ 118,106,825 278.18$



SFY 2016

Statewide

Dual Eligibles

Non-LTSS Populations

Duals

All Ages

2,280,946190,079




78 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,325,144$ 13,872 627 95.53$ 4.99$Inpatient — BH (LME/MCO) 122,074$ 215 10 567.34$ 0.46$Outpatient Hospital 2,644,254$ 35,786 1,618 73.89$ 9.97$Emergency Room 2,793,340$ 29,567 1,337 94.48$ 10.53$Physician 5,472,080$ 376,159 17,011 14.55$ 20.62$FQHC/RHC 189,733$ 10,596 479 17.91$ 0.72$Other Clinic 963,225$ 7,148 323 134.75$ 3.63$Other Practitioner 76,264$ 7,026 318 10.85$ 0.29$Therapies 16,772$ 180 8 93.00$ 0.06$Prescribed Drugs 3,210,451$ 42,481 1,921 75.57$ 12.10$Enhanced BH 923,167$ 63,503 2,872 14.54$ 3.48$B3 Services 452,057$ 51,123 2,312 8.84$ 1.70$LTSS – ICF/IID and Nursing Home 591,365,906$ 4,147,022 187,539 142.60$ 2,228.59$LTSS – State Plan Home and Community Based Services (HCBS) 26,427,909$ 3,131,771 141,627 8.44$ 99.59$LTSS – HCBS Waiver Services 198,228,680$ 61,114,927 2,763,776 3.24$ 747.03$Durable Medical Equipment 5,336,708$ 5,037,263 227,798 1.06$ 20.11$Lab and X-Ray 139,947$ 27,924 1,263 5.01$ 0.53$Optical 83,361$ 9,641 436 8.65$ 0.31$Limited Dental Services -$ - - -$ -$Transportation 5,771,240$ 624,299 28,232 9.24$ 21.75$Case Management 7,249$ 568 26 12.76$ 0.03$Patient-Centered Medical Home (PCMH) Payments 1,306,025$ 172,316 7,793 7.58$ 4.92$Subtotal (Covered Services) 846,855,589$ 74,903,388 3,191.42$

Capitation — PACE 604,743$ 1,313 59 460.51$ 2.28$Dental 2,348,579$ 35,249 1,594 66.63$ 8.85$Local Education Agency (LEA) 404$ 18 1 22.43$ 0.00$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 2,953,726$ 36,580 11.13$Total (All) 849,809,315$ 74,939,969 3,202.55$



SFY 2016

Statewide

Dual Eligibles

LTSS Populations

Duals

All Ages

265,35422,113




79 of 179


8 REGIONAL EXHIBITSThe exhibits included in Section 8 summarize the cost and utilization data for each Program Type on both astatewide and regional basis, consistent with the regional groups outlined in Section 1. These exhibits areprovided for the SFY 2015 time period in Section 8.1, and the SFY 2016 time period is included in Section 8.2. Seethe grid below highlighting the information available in each of the detailed exhibit sections.

SFY 2015Exhibit

SFY 2016Exhibit

Description

8.1.1 8.2.1 Exhibits summarize information for all populations and age groups included in the Standard Plan(Non-Duals) Program Type on a statewide and regional basis. The Standard Plan includes thefollowing populations combined:

· Aged, Blind, Disabled (ABD)· Temporary Assistance for Needy Families (TANF) and Other Related Children/Adults· NC Health Choice· Medicaid-Children’s Health Insurance Program (M-CHIP)· Maternity

8.1.2 8.2.2 Exhibits summarize information for the Foster Children and Adopted Children Population Grouping,for all ages, on a statewide and regional basis.

8.1.3 8.2.3 Exhibits summarize information for all populations and age groups included in the Behavioral Health(BH) Intellectual/Developmental Disability (I/DD) Tailored Plan Program Type, on a statewide andregional basis. The Behavioral Health I/DD Tailored Plan includes the following populationscombined:

· I/DD Non-Dual and Dual Eligibles· Serious and Persistent Mental Illness (SPMI)/Serious Emotional Disturbance (SED) Non-Dual

and Dual Eligibles· Substance Use Disorder (SUD) Non-Dual and Dual Eligibles

8.1.4 8.2.4 Exhibits summarize information for all populations and age groups included in the Non-Dual LongTerm Services and Supports (LTSS) Program Type, on a statewide and regional basis. Non-Dual LTSSexhibits include the following populations combined:

· Community Alternatives for Children (CAP/C) waiver beneficiaries· Community Alternatives for Disabled Adults (CAP/DA) waiver beneficiaries· Nursing Facility Level of Care (NFLOC)

8.1.5 8.2.5 Exhibits summarize information for all populations and age groups included in the Dual EligiblesProgram Type, on a statewide and regional basis. The Dual Eligibles exhibits include information forall duals other than those identified as eligible for the BH I/DD Tailored Plan.

80 of 179


SFY 2015 Regional Exhibits8.1Cost and utilization information for the July 1, 2014 through June 30, 2015 (SFY 2015) time period is illustrated inSection 8.1.

81 of 179



82 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 632,781,790$ 791,718 525 799.25$ 34.94$Inpatient — BH (LME/MCO) 24,935,763$ 38,515 26 647.44$ 1.38$Outpatient Hospital 408,632,947$ 1,252,678 830 326.21$ 22.56$Emergency Room 456,638,976$ 1,223,279 810 373.29$ 25.21$Physician 738,759,917$ 6,945,042 4,601 106.37$ 40.79$FQHC/RHC 47,006,527$ 436,502 289 107.69$ 2.60$Other Clinic 169,935,027$ 1,273,437 844 133.45$ 9.38$Other Practitioner 4,624,029$ 62,475 41 74.01$ 0.26$Therapies 60,104,829$ 520,353 345 115.51$ 3.32$Prescribed Drugs 1,249,510,299$ 12,752,392 8,449 97.98$ 68.98$Enhanced BH 118,652,087$ 2,755,465 1,826 43.06$ 6.55$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 2,250,878$ 12,617 8 178.41$ 0.12$LTSS – State Plan Home and Community Based Services (HCBS) 118,446,798$ 24,508,437 16,237 4.83$ 6.54$LTSS – HCBS Waiver Services 111,699$ 27,901 18 4.00$ 0.01$Durable Medical Equipment 93,689,402$ 34,490,319 22,850 2.72$ 5.17$Lab and X-Ray 83,067,017$ 4,512,213 2,989 18.41$ 4.59$Optical 22,812,762$ 1,035,207 686 22.04$ 1.26$Limited Dental Services 6,913,802$ 277,617 184 24.90$ 0.38$Transportation 35,951,155$ 1,373,322 910 26.18$ 1.98$Case Management 591,633$ 45,809 30 12.92$ 0.03$Patient-Centered Medical Home (PCMH) Payments 130,088,230$ 44,757,410 29,652 2.91$ 7.18$Subtotal (Covered Services) 4,405,505,567$ 139,092,709 243.22$

Capitation — PACE 2,057,209$ 2,874 2 715.80$ 0.11$Dental 319,370,938$ 6,857,284 4,543 46.57$ 17.63$Local Education Agency (LEA) 11,224,400$ 346,569 230 32.39$ 0.62$Children’s Developmental Services Agencies (CDSA) 2,643,684$ 101,207 67 26.12$ 0.15$Subtotal (Excluded Services) 335,296,231$ 7,307,934 18.51$Total (All) 4,740,801,798$ 146,400,643 261.73$



SFY 2015

Statewide

Standard Plan


Non-Duals

All Ages

18,113,0821,509,424




83 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 59,771,191$ 72,580 508 823.52$ 34.88$Inpatient — BH (LME/MCO) 3,506,373$ 4,074 29 860.72$ 2.05$Outpatient Hospital 56,810,630$ 199,355 1,396 284.97$ 33.15$Emergency Room 41,933,565$ 114,579 802 365.98$ 24.47$Physician 72,639,149$ 723,547 5,067 100.39$ 42.39$FQHC/RHC 9,070,269$ 72,326 506 125.41$ 5.29$Other Clinic 15,143,380$ 117,133 820 129.28$ 8.84$Other Practitioner 607,871$ 10,517 74 57.80$ 0.35$Therapies 4,472,674$ 45,093 316 99.19$ 2.61$Prescribed Drugs 129,495,044$ 1,388,021 9,720 93.29$ 75.57$Enhanced BH 13,750,619$ 281,317 1,970 48.88$ 8.02$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 223,326$ 1,472 10 151.71$ 0.13$LTSS – State Plan Home and Community Based Services (HCBS) 7,450,091$ 1,055,634 7,392 7.06$ 4.35$LTSS – HCBS Waiver Services 1,980$ 140 1 14.14$ 0.00$Durable Medical Equipment 9,875,615$ 3,266,593 22,874 3.02$ 5.76$Lab and X-Ray 6,567,579$ 338,922 2,373 19.38$ 3.83$Optical 1,964,423$ 93,862 657 20.93$ 1.15$Limited Dental Services 495,950$ 19,947 140 24.86$ 0.29$Transportation 3,271,859$ 112,098 785 29.19$ 1.91$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 11,689,428$ 4,065,599 28,469 2.88$ 6.82$Subtotal (Covered Services) 448,741,018$ 11,982,810 261.86$

Capitation — PACE 189,899$ 1,888 13 100.58$ 0.11$Dental 29,529,081$ 618,457 4,331 47.75$ 17.23$Local Education Agency (LEA) 1,644,492$ 51,341 360 32.03$ 0.96$Children’s Developmental Services Agencies (CDSA) 181,954$ 7,341 51 24.79$ 0.11$Subtotal (Excluded Services) 31,545,426$ 679,027 18.41$Total (All) 480,286,444$ 12,661,837 280.26$



SFY 2015

Region 1

Standard Plan


Non-Duals

All Ages

1,713,689142,807




84 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 105,003,304$ 130,248 513 806.18$ 34.44$Inpatient — BH (LME/MCO) 4,000,437$ 6,280 25 636.97$ 1.31$Outpatient Hospital 72,708,507$ 247,605 975 293.65$ 23.85$Emergency Room 81,055,683$ 206,409 812 392.70$ 26.59$Physician 121,203,387$ 1,199,760 4,723 101.02$ 39.76$FQHC/RHC 5,251,071$ 48,238 190 108.86$ 1.72$Other Clinic 27,267,877$ 206,760 814 131.88$ 8.94$Other Practitioner 714,432$ 9,515 37 75.08$ 0.23$Therapies 7,804,333$ 57,732 227 135.18$ 2.56$Prescribed Drugs 215,689,190$ 2,198,278 8,653 98.12$ 70.75$Enhanced BH 17,354,483$ 457,356 1,800 37.95$ 5.69$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 335,378$ 2,301 9 145.75$ 0.11$LTSS – State Plan Home and Community Based Services (HCBS) 16,703,870$ 3,202,369 12,605 5.22$ 5.48$LTSS – HCBS Waiver Services 1,903$ 506 2 3.76$ 0.00$Durable Medical Equipment 15,700,392$ 5,342,441 21,029 2.94$ 5.15$Lab and X-Ray 13,803,474$ 768,394 3,025 17.96$ 4.53$Optical 3,601,205$ 173,290 682 20.78$ 1.18$Limited Dental Services 1,297,049$ 52,098 205 24.90$ 0.43$Transportation 6,032,243$ 235,512 927 25.61$ 1.98$Case Management 51,347$ 3,976 16 12.91$ 0.02$Patient-Centered Medical Home (PCMH) Payments 22,593,297$ 7,789,663 30,662 2.90$ 7.41$Subtotal (Covered Services) 738,172,859$ 22,338,731 242.13$

Capitation — PACE 654,555$ 515 2 1,270.98$ 0.21$Dental 56,107,485$ 1,212,271 4,772 46.28$ 18.40$Local Education Agency (LEA) 1,928,703$ 58,587 231 32.92$ 0.63$Children’s Developmental Services Agencies (CDSA) 1,075,464$ 42,501 167 25.30$ 0.35$Subtotal (Excluded Services) 59,766,206$ 1,313,874 19.60$Total (All) 797,939,066$ 23,652,605 261.74$



SFY 2015

Region 2

Standard Plan


Non-Duals

All Ages

3,048,615254,051




85 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 128,476,972$ 176,078 487 729.66$ 29.60$Inpatient — BH (LME/MCO) 5,858,315$ 9,980 28 587.01$ 1.35$Outpatient Hospital 99,913,993$ 291,435 806 342.83$ 23.02$Emergency Room 115,578,477$ 287,637 795 401.82$ 26.62$Physician 180,856,977$ 1,715,150 4,741 105.45$ 41.66$FQHC/RHC 3,949,600$ 38,354 106 102.98$ 0.91$Other Clinic 40,085,973$ 301,991 835 132.74$ 9.23$Other Practitioner 1,413,018$ 17,468 48 80.89$ 0.33$Therapies 9,198,807$ 83,382 230 110.32$ 2.12$Prescribed Drugs 288,529,804$ 2,938,147 8,122 98.20$ 66.47$Enhanced BH 25,883,315$ 642,592 1,776 40.28$ 5.96$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 574,278$ 3,762 10 152.65$ 0.13$LTSS – State Plan Home and Community Based Services (HCBS) 32,765,280$ 6,667,051 18,430 4.91$ 7.55$LTSS – HCBS Waiver Services 34,071$ 9,495 26 3.59$ 0.01$Durable Medical Equipment 23,321,329$ 7,082,618 19,579 3.29$ 5.37$Lab and X-Ray 20,701,322$ 1,098,537 3,037 18.84$ 4.77$Optical 3,938,702$ 205,816 569 19.14$ 0.91$Limited Dental Services 1,398,962$ 56,171 155 24.91$ 0.32$Transportation 7,527,237$ 194,310 537 38.74$ 1.73$Case Management 201,426$ 15,592 43 12.92$ 0.05$Patient-Centered Medical Home (PCMH) Payments 30,735,685$ 10,749,419 29,715 2.86$ 7.08$Subtotal (Covered Services) 1,020,943,545$ 32,584,985 235.19$

Capitation — PACE 355,489$ 215 1 1,653.44$ 0.08$Dental 79,910,266$ 1,722,384 4,761 46.40$ 18.41$Local Education Agency (LEA) 2,681,747$ 86,182 238 31.12$ 0.62$Children’s Developmental Services Agencies (CDSA) 254,401$ 9,268 26 27.45$ 0.06$Subtotal (Excluded Services) 83,201,903$ 1,818,049 19.17$Total (All) 1,104,145,448$ 34,403,033 254.35$



SFY 2015

Region 3

Standard Plan


Non-Duals

All Ages

4,341,020361,752




86 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 126,670,738$ 151,947 522 833.65$ 36.25$Inpatient — BH (LME/MCO) 4,632,679$ 6,439 22 719.43$ 1.33$Outpatient Hospital 67,480,398$ 198,136 680 340.58$ 19.31$Emergency Room 81,111,812$ 211,404 726 383.68$ 23.21$Physician 128,431,789$ 1,181,761 4,058 108.68$ 36.75$FQHC/RHC 11,274,189$ 105,696 363 106.67$ 3.23$Other Clinic 33,807,332$ 258,829 889 130.62$ 9.67$Other Practitioner 576,557$ 7,284 25 79.15$ 0.16$Therapies 16,188,555$ 136,435 469 118.65$ 4.63$Prescribed Drugs 208,617,745$ 2,010,267 6,903 103.78$ 59.70$Enhanced BH 25,206,673$ 580,597 1,994 43.42$ 7.21$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 285,852$ 1,800 6 158.80$ 0.08$LTSS – State Plan Home and Community Based Services (HCBS) 19,369,003$ 4,358,576 14,967 4.44$ 5.54$LTSS – HCBS Waiver Services 9,273$ 446 2 20.79$ 0.00$Durable Medical Equipment 15,540,609$ 6,131,141 21,054 2.53$ 4.45$Lab and X-Ray 14,813,871$ 853,369 2,930 17.36$ 4.24$Optical 4,537,077$ 203,199 698 22.33$ 1.30$Limited Dental Services 1,257,099$ 50,404 173 24.94$ 0.36$Transportation 5,943,485$ 212,184 729 28.01$ 1.70$Case Management 110,183$ 8,535 29 12.91$ 0.03$Patient-Centered Medical Home (PCMH) Payments 24,706,857$ 8,578,349 29,457 2.88$ 7.07$Subtotal (Covered Services) 790,571,776$ 25,246,798 226.23$

Capitation — PACE 113,458$ 38 0 2,985.73$ 0.03$Dental 63,287,612$ 1,379,342 4,737 45.88$ 18.11$Local Education Agency (LEA) 2,067,509$ 62,960 216 32.84$ 0.59$Children’s Developmental Services Agencies (CDSA) 446,927$ 16,186 56 27.61$ 0.13$Subtotal (Excluded Services) 65,915,506$ 1,458,526 18.86$Total (All) 856,487,281$ 26,705,324 245.09$



SFY 2015

Region 4

Standard Plan


Non-Duals

All Ages

3,494,572291,214




87 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 114,817,538$ 150,809 589 761.35$ 37.36$Inpatient — BH (LME/MCO) 2,911,652$ 4,956 19 587.45$ 0.95$Outpatient Hospital 65,336,545$ 199,957 781 326.75$ 21.26$Emergency Room 72,653,681$ 220,837 862 328.99$ 23.64$Physician 140,436,424$ 1,250,369 4,883 112.32$ 45.70$FQHC/RHC 8,256,416$ 84,617 330 97.57$ 2.69$Other Clinic 28,291,482$ 207,182 809 136.55$ 9.21$Other Practitioner 697,106$ 9,619 38 72.47$ 0.23$Therapies 14,924,779$ 136,145 532 109.62$ 4.86$Prescribed Drugs 228,844,640$ 2,435,596 9,511 93.96$ 74.47$Enhanced BH 22,333,678$ 487,082 1,902 45.85$ 7.27$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 171,888$ 1,136 4 151.30$ 0.06$LTSS – State Plan Home and Community Based Services (HCBS) 24,068,626$ 5,364,882 20,950 4.49$ 7.83$LTSS – HCBS Waiver Services 14,874$ 4,971 19 2.99$ 0.00$Durable Medical Equipment 15,402,588$ 7,364,369 28,757 2.09$ 5.01$Lab and X-Ray 16,054,285$ 862,025 3,366 18.62$ 5.22$Optical 5,181,311$ 205,366 802 25.23$ 1.69$Limited Dental Services 1,335,137$ 53,624 209 24.90$ 0.43$Transportation 6,858,837$ 220,680 862 31.08$ 2.23$Case Management 193,854$ 14,997 59 12.93$ 0.06$Patient-Centered Medical Home (PCMH) Payments 22,087,799$ 7,474,286 29,187 2.96$ 7.19$Subtotal (Covered Services) 790,873,140$ 26,753,504 257.36$




SFY 2015

Region 5

Standard Plan


Non-Duals

All Ages

3,073,023256,085




88 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 98,042,046$ 110,057 541 890.83$ 40.15$Inpatient — BH (LME/MCO) 4,026,306$ 6,785 33 593.44$ 1.65$Outpatient Hospital 46,382,875$ 116,190 571 399.20$ 18.99$Emergency Room 64,305,757$ 182,414 896 352.53$ 26.33$Physician 95,192,191$ 874,455 4,297 108.86$ 38.98$FQHC/RHC 9,204,982$ 87,272 429 105.47$ 3.77$Other Clinic 25,338,983$ 181,543 892 139.58$ 10.38$Other Practitioner 615,045$ 8,071 40 76.20$ 0.25$Therapies 7,515,681$ 61,566 303 122.07$ 3.08$Prescribed Drugs 178,333,876$ 1,782,083 8,757 100.07$ 73.02$Enhanced BH 14,123,319$ 306,521 1,506 46.08$ 5.78$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 660,155$ 2,145 11 307.75$ 0.27$LTSS – State Plan Home and Community Based Services (HCBS) 18,089,928$ 3,859,925 18,966 4.69$ 7.41$LTSS – HCBS Waiver Services 49,599$ 12,343 61 4.02$ 0.02$Durable Medical Equipment 13,848,868$ 5,303,157 26,058 2.61$ 5.67$Lab and X-Ray 11,126,487$ 590,966 2,904 18.83$ 4.56$Optical 3,590,044$ 153,674 755 23.36$ 1.47$Limited Dental Services 1,129,605$ 45,373 223 24.90$ 0.46$Transportation 6,317,494$ 398,538 1,958 15.85$ 2.59$Case Management 34,824$ 2,709 13 12.85$ 0.01$Patient-Centered Medical Home (PCMH) Payments 18,275,165$ 6,100,094 29,974 3.00$ 7.48$Subtotal (Covered Services) 616,203,229$ 20,185,881 252.32$

Capitation — PACE 262$ 7 0 37.38$ 0.00$Dental 35,437,671$ 777,705 3,821 45.57$ 14.51$Local Education Agency (LEA) 1,472,865$ 45,999 226 32.02$ 0.60$Children’s Developmental Services Agencies (CDSA) 263,247$ 10,481 52 25.12$ 0.11$Subtotal (Excluded Services) 37,174,044$ 834,192 15.22$Total (All) 653,377,273$ 21,020,073 267.54$



SFY 2015

Region 6

Standard Plan


Non-Duals

All Ages

2,442,163203,514




89 of 179



90 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,356,883$ 6,196 296 864.62$ 21.32$Inpatient — BH (LME/MCO) 8,550,227$ 13,265 634 644.55$ 34.03$Outpatient Hospital 4,113,885$ 15,939 761 258.10$ 16.37$Emergency Room 4,123,543$ 11,934 570 345.54$ 16.41$Physician 8,271,739$ 94,723 4,524 87.33$ 32.92$FQHC/RHC 511,686$ 4,612 220 110.94$ 2.04$Other Clinic 2,366,582$ 19,955 953 118.60$ 9.42$Other Practitioner 49,504$ 655 31 75.58$ 0.20$Therapies 4,421,273$ 37,708 1,801 117.25$ 17.60$Prescribed Drugs 34,800,119$ 255,708 12,212 136.09$ 138.50$Enhanced BH 109,033,009$ 967,904 46,225 112.65$ 433.93$B3 Services 325,576$ 64,566 3,084 5.04$ 1.30$LTSS – ICF/IID and Nursing Home 1,296,081$ 11,848 566 109.39$ 5.16$LTSS – State Plan Home and Community Based Services (HCBS) 672,218$ 142,222 6,792 4.73$ 2.68$LTSS – HCBS Waiver Services 1,658,218$ 252,406 12,054 6.57$ 6.60$Durable Medical Equipment 1,824,645$ 837,222 39,984 2.18$ 7.26$Lab and X-Ray 927,302$ 51,706 2,469 17.93$ 3.69$Optical 561,736$ 26,858 1,283 20.92$ 2.24$Limited Dental Services 91,545$ 3,677 176 24.90$ 0.36$Transportation 713,400$ 34,750 1,660 20.53$ 2.84$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,482,777$ 644,818 30,795 2.30$ 5.90$Subtotal (Covered Services) 191,151,948$ 3,498,673 760.75$




SFY 2015

Statewide



Non-Duals

All Ages

251,26720,939




91 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 420,153$ 460 140 913.28$ 10.63$Inpatient — BH (LME/MCO) 1,401,248$ 1,518 461 922.99$ 35.44$Outpatient Hospital 883,202$ 4,202 1,275 210.19$ 22.34$Emergency Room 543,928$ 1,764 535 308.35$ 13.76$Physician 1,335,588$ 16,330 4,956 81.79$ 33.78$FQHC/RHC 193,526$ 1,571 477 123.18$ 4.89$Other Clinic 332,412$ 2,890 877 115.02$ 8.41$Other Practitioner 13,954$ 226 69 61.74$ 0.35$Therapies 705,859$ 6,825 2,072 103.42$ 17.85$Prescribed Drugs 5,718,006$ 42,902 13,022 133.28$ 144.63$Enhanced BH 19,022,923$ 184,496 55,999 103.11$ 481.15$B3 Services 19,719$ 4,089 1,241 4.82$ 0.50$LTSS – ICF/IID and Nursing Home 98,868$ 802 243 123.28$ 2.50$LTSS – State Plan Home and Community Based Services (HCBS) 30,812$ 4,618 1,402 6.67$ 0.78$LTSS – HCBS Waiver Services 433,896$ 52,998 16,086 8.19$ 10.97$Durable Medical Equipment 229,026$ 94,750 28,759 2.42$ 5.79$Lab and X-Ray 93,602$ 5,293 1,607 17.68$ 2.37$Optical 79,946$ 4,041 1,227 19.78$ 2.02$Limited Dental Services 13,632$ 549 167 24.83$ 0.34$Transportation 94,104$ 1,849 561 50.89$ 2.38$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 237,670$ 103,490 31,411 2.30$ 6.01$Subtotal (Covered Services) 31,902,072$ 535,664 806.91$

Capitation — PACE 19,576$ 29 9 675.03$ 0.50$Dental 911,830$ 20,600 6,253 44.26$ 23.06$Local Education Agency (LEA) 110,876$ 3,756 1,140 29.52$ 2.80$Children’s Developmental Services Agencies (CDSA) 205,282$ 8,416 2,555 24.39$ 5.19$Subtotal (Excluded Services) 1,247,564$ 32,801 31.56$Total (All) 33,149,636$ 568,465 838.47$



SFY 2015

Region 1



Non-Duals

All Ages

39,5363,295




92 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,451,465$ 1,576 446 920.86$ 34.23$Inpatient — BH (LME/MCO) 740,273$ 1,203 340 615.56$ 17.46$Outpatient Hospital 813,225$ 2,848 806 285.54$ 19.18$Emergency Room 723,364$ 2,038 577 354.92$ 17.06$Physician 1,482,203$ 16,733 4,735 88.58$ 34.96$FQHC/RHC 73,521$ 656 186 112.07$ 1.73$Other Clinic 374,156$ 3,240 917 115.48$ 8.82$Other Practitioner 7,957$ 75 21 106.09$ 0.19$Therapies 695,977$ 5,296 1,499 131.41$ 16.41$Prescribed Drugs 5,830,903$ 43,999 12,452 132.52$ 137.51$Enhanced BH 13,712,775$ 128,480 36,360 106.73$ 323.39$B3 Services 71,166$ 12,577 3,559 5.66$ 1.68$LTSS – ICF/IID and Nursing Home 106,583$ 1,771 501 60.20$ 2.51$LTSS – State Plan Home and Community Based Services (HCBS) 150,700$ 34,498 9,763 4.37$ 3.55$LTSS – HCBS Waiver Services 200,399$ 22,395 6,338 8.95$ 4.73$Durable Medical Equipment 332,351$ 153,804 43,526 2.16$ 7.84$Lab and X-Ray 174,926$ 9,457 2,676 18.50$ 4.13$Optical 89,785$ 4,333 1,226 20.72$ 2.12$Limited Dental Services 16,588$ 666 188 24.91$ 0.39$Transportation 190,120$ 20,294 5,743 9.37$ 4.48$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 265,310$ 113,537 32,131 2.34$ 6.26$Subtotal (Covered Services) 27,503,746$ 579,476 648.63$

Capitation — PACE 651$ 1 0 651.13$ 0.02$Dental 974,936$ 22,742 6,436 42.87$ 22.99$Local Education Agency (LEA) 64,481$ 2,101 595 30.69$ 1.52$Children’s Developmental Services Agencies (CDSA) 112,221$ 4,405 1,247 25.48$ 2.65$Subtotal (Excluded Services) 1,152,289$ 29,249 27.17$Total (All) 28,656,034$ 608,725 675.80$



SFY 2015

Region 2



Non-Duals

All Ages

42,4033,534




93 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 913,062$ 1,035 222 882.12$ 16.34$Inpatient — BH (LME/MCO) 1,517,798$ 2,561 550 592.75$ 27.17$Outpatient Hospital 999,340$ 3,356 721 297.78$ 17.89$Emergency Room 1,169,963$ 2,929 629 399.38$ 20.94$Physician 1,792,787$ 20,537 4,411 87.30$ 32.09$FQHC/RHC 48,798$ 457 98 106.78$ 0.87$Other Clinic 530,018$ 4,442 954 119.32$ 9.49$Other Practitioner 14,009$ 192 41 72.96$ 0.25$Therapies 1,012,296$ 8,089 1,738 125.14$ 18.12$Prescribed Drugs 7,138,131$ 54,269 11,657 131.53$ 127.77$Enhanced BH 22,003,351$ 197,996 42,530 111.13$ 393.86$B3 Services 143,801$ 32,049 6,884 4.49$ 2.57$LTSS – ICF/IID and Nursing Home 245,954$ 3,069 659 80.13$ 4.40$LTSS – State Plan Home and Community Based Services (HCBS) 321,340$ 65,831 14,140 4.88$ 5.75$LTSS – HCBS Waiver Services 389,758$ 57,503 12,352 6.78$ 6.98$Durable Medical Equipment 489,252$ 166,263 35,713 2.94$ 8.76$Lab and X-Ray 218,836$ 10,808 2,322 20.25$ 3.92$Optical 97,018$ 5,239 1,125 18.52$ 1.74$Limited Dental Services 13,294$ 535 115 24.85$ 0.24$Transportation 155,568$ 6,756 1,451 23.03$ 2.78$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 354,455$ 150,542 32,336 2.35$ 6.34$Subtotal (Covered Services) 39,568,832$ 794,459 708.28$

Capitation — PACE 651$ 2 0 325.57$ 0.01$Dental 1,254,645$ 29,222 6,277 42.93$ 22.46$Local Education Agency (LEA) 159,377$ 5,135 1,103 31.04$ 2.85$Children’s Developmental Services Agencies (CDSA) 250,533$ 9,673 2,078 25.90$ 4.48$Subtotal (Excluded Services) 1,665,206$ 44,032 29.81$Total (All) 41,234,037$ 838,490 738.09$



SFY 2015

Region 3



Non-Duals

All Ages

55,8664,656




94 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,209,113$ 1,488 385 812.52$ 26.10$Inpatient — BH (LME/MCO) 2,991,563$ 4,757 1,232 628.87$ 64.58$Outpatient Hospital 600,092$ 2,359 611 254.38$ 12.95$Emergency Room 720,246$ 2,068 536 348.26$ 15.55$Physician 1,454,408$ 16,000 4,144 90.90$ 31.40$FQHC/RHC 76,764$ 738 191 104.01$ 1.66$Other Clinic 435,158$ 3,578 927 121.62$ 9.39$Other Practitioner 4,264$ 50 13 85.28$ 0.09$Therapies 869,219$ 7,357 1,906 118.14$ 18.76$Prescribed Drugs 5,947,941$ 43,285 11,212 137.41$ 128.39$Enhanced BH 22,820,152$ 187,393 48,541 121.78$ 492.60$B3 Services 67,712$ 10,866 2,815 6.23$ 1.46$LTSS – ICF/IID and Nursing Home 356,244$ 2,080 539 171.25$ 7.69$LTSS – State Plan Home and Community Based Services (HCBS) 78,876$ 8,193 2,122 9.63$ 1.70$LTSS – HCBS Waiver Services 444,001$ 78,119 20,236 5.68$ 9.58$Durable Medical Equipment 390,749$ 182,638 47,309 2.14$ 8.43$Lab and X-Ray 185,347$ 11,446 2,965 16.19$ 4.00$Optical 110,317$ 5,029 1,303 21.94$ 2.38$Limited Dental Services 12,854$ 515 133 24.96$ 0.28$Transportation 108,060$ 1,729 448 62.52$ 2.33$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 246,059$ 110,057 28,508 2.24$ 5.31$Subtotal (Covered Services) 39,129,139$ 679,745 844.65$

Capitation — PACE -$ - - -$ -$Dental 1,010,256$ 23,020 5,963 43.89$ 21.81$Local Education Agency (LEA) 80,762$ 2,717 704 29.72$ 1.74$Children’s Developmental Services Agencies (CDSA) 85,980$ 3,414 884 25.18$ 1.86$Subtotal (Excluded Services) 1,176,998$ 29,151 25.41$Total (All) 40,306,137$ 708,896 870.05$



SFY 2015

Region 4



Non-Duals

All Ages

46,3263,861




95 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 888,406$ 1,118 326 794.47$ 21.58$Inpatient — BH (LME/MCO) 1,205,758$ 2,033 593 593.11$ 29.29$Outpatient Hospital 438,483$ 1,893 552 231.63$ 10.65$Emergency Room 575,905$ 1,943 566 296.39$ 13.99$Physician 1,391,964$ 15,850 4,621 87.82$ 33.82$FQHC/RHC 64,006$ 651 190 98.32$ 1.56$Other Clinic 435,893$ 3,709 1,081 117.52$ 10.59$Other Practitioner 4,380$ 56 16 78.21$ 0.11$Therapies 761,119$ 7,076 2,063 107.56$ 18.49$Prescribed Drugs 5,520,880$ 40,994 11,952 134.68$ 134.13$Enhanced BH 19,387,680$ 167,870 48,942 115.49$ 471.03$B3 Services 8,898$ 2,243 654 3.97$ 0.22$LTSS – ICF/IID and Nursing Home 287,680$ 2,897 845 99.30$ 6.99$LTSS – State Plan Home and Community Based Services (HCBS) 47,093$ 15,602 4,549 3.02$ 1.14$LTSS – HCBS Waiver Services 127,510$ 28,921 8,432 4.41$ 3.10$Durable Medical Equipment 227,644$ 175,439 51,148 1.30$ 5.53$Lab and X-Ray 161,091$ 9,186 2,678 17.54$ 3.91$Optical 116,026$ 5,037 1,469 23.03$ 2.82$Limited Dental Services 23,603$ 949 277 24.87$ 0.57$Transportation 96,278$ 1,495 436 64.39$ 2.34$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 227,325$ 100,976 29,439 2.25$ 5.52$Subtotal (Covered Services) 31,997,621$ 585,937 777.40$

Capitation — PACE -$ - - -$ -$Dental 935,922$ 20,692 6,033 45.23$ 22.74$Local Education Agency (LEA) 50,874$ 1,631 476 31.19$ 1.24$Children’s Developmental Services Agencies (CDSA) 114,037$ 4,381 1,277 26.03$ 2.77$Subtotal (Excluded Services) 1,100,833$ 26,704 26.75$Total (All) 33,098,454$ 612,641 804.14$



SFY 2015

Region 5



Non-Duals

All Ages

41,1603,430




96 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 474,685$ 518 239 916.35$ 18.27$Inpatient — BH (LME/MCO) 693,587$ 1,194 552 580.84$ 26.70$Outpatient Hospital 379,542$ 1,281 592 296.29$ 14.61$Emergency Room 390,137$ 1,191 550 327.57$ 15.02$Physician 814,789$ 9,275 4,285 87.84$ 31.37$FQHC/RHC 55,069$ 539 249 102.17$ 2.12$Other Clinic 258,946$ 2,095 968 123.60$ 9.97$Other Practitioner 4,939$ 56 26 88.19$ 0.19$Therapies 376,803$ 3,064 1,416 122.97$ 14.51$Prescribed Drugs 4,644,258$ 30,259 13,979 153.48$ 178.79$Enhanced BH 12,086,128$ 101,669 46,968 118.88$ 465.28$B3 Services 14,280$ 2,742 1,267 5.21$ 0.55$LTSS – ICF/IID and Nursing Home 200,752$ 1,229 568 163.35$ 7.73$LTSS – State Plan Home and Community Based Services (HCBS) 43,397$ 13,481 6,228 3.22$ 1.67$LTSS – HCBS Waiver Services 62,655$ 12,470 5,761 5.02$ 2.41$Durable Medical Equipment 155,623$ 64,328 29,717 2.42$ 5.99$Lab and X-Ray 93,502$ 5,516 2,548 16.95$ 3.60$Optical 68,644$ 3,179 1,469 21.59$ 2.64$Limited Dental Services 11,574$ 463 214 25.00$ 0.45$Transportation 69,269$ 2,627 1,213 26.37$ 2.67$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 151,958$ 66,216 30,589 2.29$ 5.85$Subtotal (Covered Services) 21,050,538$ 323,392 810.38$

Capitation — PACE -$ - - -$ -$Dental 502,870$ 11,889 5,492 42.30$ 19.36$Local Education Agency (LEA) 38,546$ 1,107 511 34.82$ 1.48$Children’s Developmental Services Agencies (CDSA) 72,463$ 2,791 1,289 25.96$ 2.79$Subtotal (Excluded Services) 613,880$ 15,787 23.63$Total (All) 21,664,418$ 339,179 834.02$



SFY 2015

Region 6



Non-Duals

All Ages

25,9762,165




97 of 179



98 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 113,113,624$ 142,792 1,341 792.16$ 88.54$Inpatient — BH (LME/MCO) 67,283,134$ 113,142 1,063 594.68$ 52.67$Outpatient Hospital 53,897,007$ 189,427 1,779 284.53$ 42.19$Emergency Room 65,891,474$ 192,100 1,804 343.01$ 51.58$Physician 90,598,045$ 944,944 8,876 95.88$ 70.91$FQHC/RHC 4,103,033$ 47,605 447 86.19$ 3.21$Other Clinic 9,257,774$ 64,098 602 144.43$ 7.25$Other Practitioner 552,441$ 14,221 134 38.85$ 0.43$Therapies 37,424,243$ 324,161 3,045 115.45$ 29.29$Prescribed Drugs 288,680,905$ 2,150,940 20,203 134.21$ 225.96$Enhanced BH 513,496,854$ 20,003,292 187,888 25.67$ 401.93$B3 Services 34,940,267$ 4,100,325 38,514 8.52$ 27.35$LTSS – ICF/IID and Nursing Home 486,693,818$ 1,268,427 11,914 383.70$ 380.95$LTSS – State Plan Home and Community Based Services (HCBS) 150,127,857$ 37,316,181 350,505 4.02$ 117.51$LTSS – HCBS Waiver Services 588,573,092$ 88,712,686 833,265 6.63$ 460.70$Durable Medical Equipment 52,674,647$ 27,033,218 253,919 1.95$ 41.23$Lab and X-Ray 30,611,559$ 1,497,294 14,064 20.44$ 23.96$Optical 1,413,682$ 65,895 619 21.45$ 1.11$Limited Dental Services 382,328$ 15,375 144 24.87$ 0.30$Transportation 25,360,438$ 1,984,680 18,642 12.78$ 19.85$Case Management 257,669$ 20,034 188 12.86$ 0.20$Patient-Centered Medical Home (PCMH) Payments 13,606,513$ 2,711,915 25,473 5.02$ 10.65$Subtotal (Covered Services) 2,628,940,402$ 188,912,752 2,057.77$

Capitation — PACE 1,191,551$ 685 6 1,739.49$ 0.93$Dental 23,562,834$ 443,886 4,169 53.08$ 18.44$Local Education Agency (LEA) 6,408,902$ 210,483 1,977 30.45$ 5.02$Children’s Developmental Services Agencies (CDSA) 9,106,820$ 366,841 3,446 24.82$ 7.13$Subtotal (Excluded Services) 40,270,107$ 1,021,895 31.52$Total (All) 2,669,210,508$ 189,934,647 2,089.29$



SFY 2015

Statewide



All Eligibles

All Ages

1,277,567106,464




99 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 12,793,929$ 16,240 1,235 787.80$ 81.10$Inpatient — BH (LME/MCO) 13,279,482$ 15,874 1,207 836.57$ 84.18$Outpatient Hospital 7,695,745$ 30,001 2,282 256.52$ 48.78$Emergency Room 7,812,779$ 24,164 1,838 323.33$ 49.53$Physician 10,253,292$ 115,797 8,808 88.55$ 65.00$FQHC/RHC 1,002,840$ 10,248 780 97.85$ 6.36$Other Clinic 1,078,030$ 8,055 613 133.83$ 6.83$Other Practitioner 92,331$ 2,252 171 41.00$ 0.59$Therapies 4,358,101$ 40,794 3,103 106.83$ 27.63$Prescribed Drugs 36,480,017$ 280,936 21,370 129.85$ 231.25$Enhanced BH 62,621,167$ 1,752,494 133,309 35.73$ 396.96$B3 Services 2,037,124$ 249,316 18,965 8.17$ 12.91$LTSS – ICF/IID and Nursing Home 40,931,593$ 119,884 9,119 341.43$ 259.47$LTSS – State Plan Home and Community Based Services (HCBS) 12,127,113$ 3,094,873 235,422 3.92$ 76.87$LTSS – HCBS Waiver Services 77,964,222$ 10,463,038 795,905 7.45$ 494.22$Durable Medical Equipment 5,462,403$ 2,788,701 212,132 1.96$ 34.63$Lab and X-Ray 4,400,627$ 204,035 15,521 21.57$ 27.90$Optical 156,901$ 7,728 588 20.30$ 0.99$Limited Dental Services 37,020$ 1,495 114 24.76$ 0.23$Transportation 2,151,474$ 50,017 3,805 43.01$ 13.64$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,550,919$ 323,191 24,585 4.80$ 9.83$Subtotal (Covered Services) 304,287,108$ 19,599,134 1,928.88$




SFY 2015

Region 1



All Eligibles

All Ages

157,75313,146




100 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 17,158,200$ 19,824 1,290 865.54$ 93.07$Inpatient — BH (LME/MCO) 7,333,641$ 13,577 884 540.16$ 39.78$Outpatient Hospital 8,599,411$ 33,535 2,183 256.43$ 46.64$Emergency Room 9,406,305$ 28,433 1,851 330.83$ 51.02$Physician 12,121,652$ 135,765 8,837 89.28$ 65.75$FQHC/RHC 297,685$ 3,157 205 94.29$ 1.61$Other Clinic 1,119,135$ 8,167 532 137.03$ 6.07$Other Practitioner 64,982$ 1,968 128 33.02$ 0.35$Therapies 4,426,524$ 36,014 2,344 122.91$ 24.01$Prescribed Drugs 43,010,417$ 312,397 20,334 137.68$ 233.29$Enhanced BH 67,131,224$ 3,140,015 204,383 21.38$ 364.13$B3 Services 2,389,773$ 278,668 18,138 8.58$ 12.96$LTSS – ICF/IID and Nursing Home 79,383,980$ 194,347 12,650 408.46$ 430.59$LTSS – State Plan Home and Community Based Services (HCBS) 26,257,047$ 6,502,324 423,234 4.04$ 142.42$LTSS – HCBS Waiver Services 105,451,872$ 16,530,195 1,075,945 6.38$ 571.99$Durable Medical Equipment 9,032,617$ 4,658,921 303,248 1.94$ 48.99$Lab and X-Ray 3,532,017$ 170,046 11,068 20.77$ 19.16$Optical 179,002$ 9,056 589 19.77$ 0.97$Limited Dental Services 34,129$ 1,416 92 24.10$ 0.19$Transportation 7,146,660$ 754,159 49,088 9.48$ 38.76$Case Management 10,329$ 797 52 12.96$ 0.06$Patient-Centered Medical Home (PCMH) Payments 2,094,364$ 392,601 25,554 5.33$ 11.36$Subtotal (Covered Services) 406,180,966$ 33,225,383 2,203.18$

Capitation — PACE 222,119$ 111 7 2,001.07$ 1.20$Dental 3,450,664$ 64,880 4,223 53.19$ 18.72$Local Education Agency (LEA) 863,443$ 27,822 1,811 31.03$ 4.68$Children’s Developmental Services Agencies (CDSA) 846,691$ 33,616 2,188 25.19$ 4.59$Subtotal (Excluded Services) 5,382,918$ 126,429 29.20$Total (All) 411,563,884$ 33,351,812 2,232.38$



SFY 2015

Region 2



All Eligibles

All Ages

184,36115,363




101 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 23,488,817$ 32,984 1,310 712.13$ 77.76$Inpatient — BH (LME/MCO) 13,484,688$ 26,484 1,052 509.16$ 44.64$Outpatient Hospital 14,860,971$ 47,674 1,894 311.72$ 49.20$Emergency Room 18,255,035$ 47,419 1,884 384.98$ 60.43$Physician 24,373,921$ 237,920 9,451 102.45$ 80.69$FQHC/RHC 394,539$ 5,339 212 73.89$ 1.31$Other Clinic 2,320,563$ 16,313 648 142.25$ 7.68$Other Practitioner 144,674$ 3,556 141 40.68$ 0.48$Therapies 10,439,689$ 86,410 3,433 120.82$ 34.56$Prescribed Drugs 69,759,852$ 488,788 19,417 142.72$ 230.93$Enhanced BH 105,010,986$ 4,341,824 172,477 24.19$ 347.63$B3 Services 10,636,849$ 1,355,439 53,844 7.85$ 35.21$LTSS – ICF/IID and Nursing Home 88,904,282$ 203,250 8,074 437.41$ 294.31$LTSS – State Plan Home and Community Based Services (HCBS) 36,426,720$ 8,731,697 346,862 4.17$ 120.59$LTSS – HCBS Waiver Services 151,345,482$ 22,887,763 909,204 6.61$ 501.01$Durable Medical Equipment 12,903,192$ 5,754,980 228,613 2.24$ 42.71$Lab and X-Ray 9,624,702$ 480,027 19,069 20.05$ 31.86$Optical 245,653$ 13,208 525 18.60$ 0.81$Limited Dental Services 112,427$ 4,500 179 24.98$ 0.37$Transportation 4,226,269$ 122,818 4,879 34.41$ 13.99$Case Management 115,689$ 8,959 356 12.91$ 0.38$Patient-Centered Medical Home (PCMH) Payments 3,192,593$ 659,209 26,187 4.84$ 10.57$Subtotal (Covered Services) 600,267,592$ 45,556,562 1,987.11$




SFY 2015

Region 3



All Eligibles

All Ages

302,08125,173




102 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 22,845,182$ 28,276 1,299 807.95$ 87.48$Inpatient — BH (LME/MCO) 16,095,587$ 25,921 1,191 620.95$ 61.63$Outpatient Hospital 10,150,031$ 35,534 1,633 285.64$ 38.87$Emergency Room 13,264,592$ 36,150 1,661 366.93$ 50.79$Physician 16,676,591$ 176,095 8,091 94.70$ 63.86$FQHC/RHC 1,025,507$ 11,565 531 88.67$ 3.93$Other Clinic 2,044,265$ 12,952 595 157.83$ 7.83$Other Practitioner 92,784$ 2,289 105 40.53$ 0.36$Therapies 7,789,884$ 68,612 3,153 113.54$ 29.83$Prescribed Drugs 54,222,835$ 407,456 18,722 133.08$ 207.63$Enhanced BH 125,859,243$ 4,373,331 200,952 28.78$ 481.93$B3 Services 13,878,332$ 1,347,746 61,928 10.30$ 53.14$LTSS – ICF/IID and Nursing Home 110,142,479$ 257,580 11,836 427.60$ 421.75$LTSS – State Plan Home and Community Based Services (HCBS) 25,951,869$ 6,632,195 304,745 3.91$ 99.37$LTSS – HCBS Waiver Services 101,726,644$ 14,448,928 663,919 7.04$ 389.52$Durable Medical Equipment 9,337,032$ 5,070,834 233,002 1.84$ 35.75$Lab and X-Ray 6,195,111$ 306,224 14,071 20.23$ 23.72$Optical 281,140$ 12,651 581 22.22$ 1.08$Limited Dental Services 61,298$ 2,453 113 24.99$ 0.23$Transportation 4,405,493$ 350,728 16,116 12.56$ 16.87$Case Management 56,587$ 4,393 202 12.88$ 0.22$Patient-Centered Medical Home (PCMH) Payments 2,730,365$ 552,879 25,404 4.94$ 10.45$Subtotal (Covered Services) 544,832,852$ 34,164,792 2,086.23$




SFY 2015

Region 4



All Eligibles

All Ages

261,15721,763




103 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 19,980,260$ 25,702 1,521 777.37$ 98.50$Inpatient — BH (LME/MCO) 8,241,100$ 14,409 852 571.94$ 40.63$Outpatient Hospital 7,363,378$ 25,725 1,522 286.23$ 36.30$Emergency Room 9,184,266$ 30,701 1,816 299.15$ 45.28$Physician 15,594,170$ 157,941 9,344 98.73$ 76.88$FQHC/RHC 727,024$ 9,031 534 80.50$ 3.58$Other Clinic 1,346,472$ 10,028 593 134.27$ 6.64$Other Practitioner 74,274$ 1,922 114 38.64$ 0.37$Therapies 6,747,669$ 61,974 3,666 108.88$ 33.27$Prescribed Drugs 46,888,081$ 370,041 21,892 126.71$ 231.16$Enhanced BH 90,689,820$ 3,542,228 209,558 25.60$ 447.10$B3 Services 1,323,246$ 200,172 11,842 6.61$ 6.52$LTSS – ICF/IID and Nursing Home 64,567,263$ 190,196 11,252 339.48$ 318.32$LTSS – State Plan Home and Community Based Services (HCBS) 25,982,650$ 6,535,988 386,669 3.98$ 128.09$LTSS – HCBS Waiver Services 83,050,188$ 13,612,436 805,311 6.10$ 409.44$Durable Medical Equipment 8,473,367$ 4,674,083 276,518 1.81$ 41.77$Lab and X-Ray 3,520,453$ 177,156 10,481 19.87$ 17.36$Optical 332,567$ 13,891 822 23.94$ 1.64$Limited Dental Services 69,505$ 2,787 165 24.94$ 0.34$Transportation 3,167,208$ 237,860 14,072 13.32$ 15.61$Case Management 57,835$ 4,532 268 12.76$ 0.29$Patient-Centered Medical Home (PCMH) Payments 2,183,498$ 429,133 25,387 5.09$ 10.76$Subtotal (Covered Services) 399,564,294$ 30,327,940 1,969.85$

Capitation — PACE 89,083$ 26 2 3,426.25$ 0.44$Dental 3,839,105$ 72,327 4,279 53.08$ 18.93$Local Education Agency (LEA) 807,770$ 26,097 1,544 30.95$ 3.98$Children’s Developmental Services Agencies (CDSA) 1,481,559$ 64,566 3,820 22.95$ 7.30$Subtotal (Excluded Services) 6,217,518$ 163,016 30.65$Total (All) 405,781,812$ 30,490,956 2,000.50$



SFY 2015

Region 5



All Eligibles

All Ages

202,84016,903




104 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 16,847,236$ 19,766 1,400 852.33$ 99.47$Inpatient — BH (LME/MCO) 8,848,635$ 16,878 1,196 524.27$ 52.24$Outpatient Hospital 5,227,471$ 16,958 1,201 308.26$ 30.86$Emergency Room 7,968,497$ 25,234 1,788 315.79$ 47.05$Physician 11,578,418$ 121,425 8,603 95.35$ 68.36$FQHC/RHC 655,438$ 8,263 585 79.32$ 3.87$Other Clinic 1,349,310$ 8,581 608 157.24$ 7.97$Other Practitioner 83,395$ 2,234 158 37.33$ 0.49$Therapies 3,662,377$ 30,356 2,151 120.65$ 21.62$Prescribed Drugs 38,319,703$ 291,322 20,640 131.54$ 226.24$Enhanced BH 62,184,414$ 2,853,400 202,160 21.79$ 367.14$B3 Services 4,674,943$ 668,985 47,397 6.99$ 27.60$LTSS – ICF/IID and Nursing Home 102,764,221$ 303,170 21,479 338.97$ 606.73$LTSS – State Plan Home and Community Based Services (HCBS) 23,382,457$ 5,819,103 412,276 4.02$ 138.05$LTSS – HCBS Waiver Services 69,034,684$ 10,770,325 763,064 6.41$ 407.58$Durable Medical Equipment 7,466,036$ 4,085,698 289,466 1.83$ 44.08$Lab and X-Ray 3,338,650$ 159,806 11,322 20.89$ 19.71$Optical 218,419$ 9,361 663 23.33$ 1.29$Limited Dental Services 67,949$ 2,724 193 24.94$ 0.40$Transportation 4,263,334$ 469,097 33,235 9.09$ 25.17$Case Management 17,229$ 1,353 96 12.73$ 0.10$Patient-Centered Medical Home (PCMH) Payments 1,854,775$ 354,902 25,144 5.23$ 10.95$Subtotal (Covered Services) 373,807,590$ 26,038,942 2,206.98$

Capitation — PACE -$ - - -$ -$Dental 2,431,220$ 47,378 3,357 51.32$ 14.35$Local Education Agency (LEA) 469,531$ 14,223 1,008 33.01$ 2.77$Children’s Developmental Services Agencies (CDSA) 1,098,472$ 43,739 3,099 25.11$ 6.49$Subtotal (Excluded Services) 3,999,223$ 105,340 23.61$Total (All) 377,806,813$ 26,144,282 2,230.59$



SFY 2015

Region 6



All Eligibles

All Ages

169,37514,115




105 of 179



106 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 26,503,741$ 28,782 5,696 920.84$ 437.10$Inpatient — BH (LME/MCO) 696,447$ 1,024 203 680.05$ 11.49$Outpatient Hospital 9,054,814$ 27,713 5,484 326.74$ 149.33$Emergency Room 4,991,127$ 9,265 1,834 538.71$ 82.31$Physician 14,048,338$ 105,014 20,782 133.78$ 231.68$FQHC/RHC 368,284$ 3,532 699 104.27$ 6.07$Other Clinic 1,529,279$ 2,298 455 665.46$ 25.22$Other Practitioner 121,027$ 1,767 350 68.49$ 2.00$Therapies 4,123,426$ 33,355 6,601 123.62$ 68.00$Prescribed Drugs 50,329,348$ 414,900 82,110 121.30$ 830.02$Enhanced BH 1,298,361$ 41,970 8,306 30.94$ 21.41$B3 Services 409,265$ 65,361 12,935 6.26$ 6.75$LTSS – ICF/IID and Nursing Home 79,785,260$ 464,710 91,967 171.69$ 1,315.81$LTSS – State Plan Home and Community Based Services (HCBS) 13,095,129$ 2,210,080 437,380 5.93$ 215.96$LTSS – HCBS Waiver Services 120,458,583$ 24,532,060 4,854,950 4.91$ 1,986.59$Durable Medical Equipment 24,264,889$ 8,069,724 1,597,016 3.01$ 400.17$Lab and X-Ray 890,980$ 60,214 11,916 14.80$ 14.69$Optical 111,946$ 2,975 589 37.63$ 1.85$Limited Dental Services 3,375$ 144 28 23.43$ 0.06$Transportation 3,097,472$ 205,146 40,599 15.10$ 51.08$Case Management 3,816$ 295 58 12.93$ 0.06$Patient-Centered Medical Home (PCMH) Payments 646,735$ 96,024 19,003 6.74$ 10.67$Subtotal (Covered Services) 355,831,641$ 36,376,354 5,868.32$




SFY 2015

Statewide



Non-Duals

All Ages

60,6365,053




107 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 2,968,404$ 3,152 4,996 941.65$ 392.02$Inpatient — BH (LME/MCO) 289,798$ 323 512 897.21$ 38.27$Outpatient Hospital 1,336,567$ 4,521 7,165 295.64$ 176.51$Emergency Room 647,043$ 1,275 2,021 507.49$ 85.45$Physician 1,751,076$ 13,128 20,806 133.38$ 231.26$FQHC/RHC 79,245$ 660 1,046 120.06$ 10.47$Other Clinic 87,650$ 239 379 366.72$ 11.58$Other Practitioner 37,425$ 313 496 119.57$ 4.94$Therapies 513,204$ 4,663 7,390 110.05$ 67.78$Prescribed Drugs 6,678,409$ 55,103 87,326 121.20$ 881.99$Enhanced BH 254,401$ 5,651 8,956 45.02$ 33.60$B3 Services 61,359$ 11,271 17,862 5.44$ 8.10$LTSS – ICF/IID and Nursing Home 10,070,537$ 54,610 86,546 184.41$ 1,329.97$LTSS – State Plan Home and Community Based Services (HCBS) 1,663,647$ 162,050 256,815 10.27$ 219.71$LTSS – HCBS Waiver Services 13,470,067$ 2,719,541 4,309,890 4.95$ 1,778.93$Durable Medical Equipment 2,554,698$ 799,719 1,267,384 3.19$ 337.39$Lab and X-Ray 99,725$ 5,190 8,225 19.21$ 13.17$Optical 18,629$ 466 739 39.98$ 2.46$Limited Dental Services 533$ 22 35 24.21$ 0.07$Transportation 299,953$ 12,074 19,134 24.84$ 39.61$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 84,443$ 12,231 19,384 6.90$ 11.15$Subtotal (Covered Services) 42,966,813$ 3,866,204 5,674.43$

Capitation — PACE 17,716$ 25 40 708.65$ 2.34$Dental 104,743$ 1,690 2,678 61.98$ 13.83$Local Education Agency (LEA) 111,021$ 3,929 6,227 28.26$ 14.66$Children’s Developmental Services Agencies (CDSA) 70,015$ 2,910 4,612 24.06$ 9.25$Subtotal (Excluded Services) 303,495$ 8,554 40.08$Total (All) 43,270,308$ 3,874,758 5,714.52$



SFY 2015

Region 1



Non-Duals

All Ages

7,572631




108 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,327,929$ 5,050 5,973 1,055.12$ 525.18$Inpatient — BH (LME/MCO) 70,946$ 118 140 599.69$ 6.99$Outpatient Hospital 1,720,899$ 4,865 5,755 353.73$ 169.63$Emergency Room 841,956$ 1,641 1,941 513.07$ 82.99$Physician 2,178,161$ 17,178 20,319 126.80$ 214.70$FQHC/RHC 36,958$ 335 396 110.32$ 3.64$Other Clinic 210,340$ 349 413 602.68$ 20.73$Other Practitioner 17,775$ 284 336 62.59$ 1.75$Therapies 477,243$ 3,120 3,691 152.96$ 47.04$Prescribed Drugs 7,737,886$ 73,029 86,382 105.96$ 762.73$Enhanced BH 193,645$ 6,156 7,281 31.46$ 19.09$B3 Services 61,190$ 13,797 16,320 4.44$ 6.03$LTSS – ICF/IID and Nursing Home 12,894,083$ 76,138 90,060 169.35$ 1,270.98$LTSS – State Plan Home and Community Based Services (HCBS) 2,160,918$ 504,403 596,633 4.28$ 213.00$LTSS – HCBS Waiver Services 20,800,810$ 4,044,133 4,783,598 5.14$ 2,050.35$Durable Medical Equipment 4,508,351$ 1,357,687 1,605,938 3.32$ 444.39$Lab and X-Ray 170,900$ 11,909 14,087 14.35$ 16.85$Optical 15,758$ 426 504 36.99$ 1.55$Limited Dental Services 650$ 34 40 19.11$ 0.06$Transportation 416,134$ 15,482 18,313 26.88$ 41.02$Case Management 207$ 16 19 12.96$ 0.02$Patient-Centered Medical Home (PCMH) Payments 113,424$ 16,632 19,673 6.82$ 11.18$Subtotal (Covered Services) 59,956,164$ 6,152,782 5,909.92$




SFY 2015

Region 2



Non-Duals

All Ages

10,145845




109 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,285,796$ 6,245 5,268 846.45$ 371.58$Inpatient — BH (LME/MCO) 191,944$ 379 320 505.94$ 13.49$Outpatient Hospital 2,416,060$ 5,964 5,031 405.11$ 169.85$Emergency Room 1,210,859$ 1,968 1,660 615.26$ 85.12$Physician 3,534,987$ 27,328 23,053 129.35$ 248.51$FQHC/RHC 38,452$ 398 336 96.61$ 2.70$Other Clinic 311,316$ 490 413 635.32$ 21.89$Other Practitioner 22,323$ 499 421 44.73$ 1.57$Therapies 1,172,608$ 9,002 7,594 130.26$ 82.43$Prescribed Drugs 12,234,467$ 98,392 83,002 124.34$ 860.07$Enhanced BH 323,393$ 13,837 11,673 23.37$ 22.73$B3 Services 186,775$ 23,185 19,559 8.06$ 13.13$LTSS – ICF/IID and Nursing Home 17,322,379$ 106,802 90,097 162.19$ 1,217.74$LTSS – State Plan Home and Community Based Services (HCBS) 3,946,725$ 493,407 416,231 8.00$ 277.45$LTSS – HCBS Waiver Services 32,371,556$ 6,102,532 5,148,006 5.30$ 2,275.68$Durable Medical Equipment 5,895,426$ 1,620,041 1,366,642 3.64$ 414.44$Lab and X-Ray 238,292$ 16,439 13,868 14.50$ 16.75$Optical 19,336$ 611 515 31.65$ 1.36$Limited Dental Services 697$ 28 24 24.90$ 0.05$Transportation 502,218$ 12,513 10,556 40.13$ 35.31$Case Management 700$ 54 46 12.96$ 0.05$Patient-Centered Medical Home (PCMH) Payments 153,753$ 22,794 19,229 6.75$ 10.81$Subtotal (Covered Services) 87,380,064$ 8,562,909 6,142.71$

Capitation — PACE -$ - - -$ -$Dental 188,288$ 3,513 2,964 53.60$ 13.24$Local Education Agency (LEA) 160,716$ 5,662 4,776 28.39$ 11.30$Children’s Developmental Services Agencies (CDSA) 26,864$ 1,179 995 22.78$ 1.89$Subtotal (Excluded Services) 375,867$ 10,354 26.42$Total (All) 87,755,931$ 8,573,264 6,169.13$



SFY 2015

Region 3



Non-Duals

All Ages

14,2251,185




110 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,088,567$ 5,039 5,365 1,009.74$ 451.47$Inpatient — BH (LME/MCO) 41,899$ 41 44 1,020.96$ 3.72$Outpatient Hospital 1,497,477$ 5,032 5,357 297.59$ 132.86$Emergency Room 672,071$ 1,313 1,398 511.86$ 59.63$Physician 2,445,133$ 17,606 18,744 138.88$ 216.94$FQHC/RHC 53,494$ 492 524 108.73$ 4.75$Other Clinic 183,631$ 359 382 511.49$ 16.29$Other Practitioner 9,619$ 141 150 68.21$ 0.85$Therapies 1,195,457$ 10,253 10,917 116.59$ 106.06$Prescribed Drugs 8,120,991$ 61,651 65,639 131.73$ 720.52$Enhanced BH 249,690$ 6,263 6,668 39.87$ 22.15$B3 Services 39,075$ 5,613 5,976 6.96$ 3.47$LTSS – ICF/IID and Nursing Home 13,444,537$ 75,388 80,264 178.34$ 1,192.84$LTSS – State Plan Home and Community Based Services (HCBS) 1,989,746$ 359,007 382,227 5.54$ 176.54$LTSS – HCBS Waiver Services 23,801,893$ 4,728,518 5,034,355 5.03$ 2,111.78$Durable Medical Equipment 5,241,567$ 1,689,178 1,798,433 3.10$ 465.05$Lab and X-Ray 123,253$ 9,647 10,271 12.78$ 10.94$Optical 15,288$ 547 582 27.95$ 1.36$Limited Dental Services 747$ 30 32 24.90$ 0.07$Transportation 468,151$ 25,670 27,331 18.24$ 41.54$Case Management 657$ 51 54 12.87$ 0.06$Patient-Centered Medical Home (PCMH) Payments 114,825$ 18,417 19,608 6.23$ 10.19$Subtotal (Covered Services) 64,797,767$ 7,020,257 5,749.07$

Capitation — PACE -$ - - -$ -$Dental 140,644$ 2,795 2,976 50.32$ 12.48$Local Education Agency (LEA) 184,385$ 8,089 8,612 22.79$ 16.36$Children’s Developmental Services Agencies (CDSA) 16,959$ 746 794 22.73$ 1.50$Subtotal (Excluded Services) 341,989$ 11,630 30.34$Total (All) 65,139,756$ 7,031,887 5,779.41$



SFY 2015

Region 4



Non-Duals

All Ages

11,271939




111 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,625,336$ 5,519 6,794 838.10$ 474.54$Inpatient — BH (LME/MCO) 13,076$ 20 25 651.86$ 1.34$Outpatient Hospital 1,195,497$ 4,014 4,942 297.83$ 122.65$Emergency Room 769,625$ 1,573 1,937 489.28$ 78.96$Physician 2,305,474$ 16,823 20,711 137.05$ 236.53$FQHC/RHC 69,901$ 715 880 97.76$ 7.17$Other Clinic 276,728$ 398 490 695.28$ 28.39$Other Practitioner 15,284$ 277 341 55.18$ 1.57$Therapies 561,836$ 4,609 5,675 121.90$ 57.64$Prescribed Drugs 9,089,604$ 68,568 84,417 132.56$ 932.55$Enhanced BH 142,261$ 5,809 7,152 24.49$ 14.60$B3 Services 27,470$ 4,685 5,768 5.86$ 2.82$LTSS – ICF/IID and Nursing Home 13,321,038$ 76,290 93,924 174.61$ 1,366.68$LTSS – State Plan Home and Community Based Services (HCBS) 1,917,106$ 398,736 490,903 4.81$ 196.69$LTSS – HCBS Waiver Services 18,160,060$ 4,296,524 5,289,657 4.23$ 1,863.14$Durable Medical Equipment 3,547,426$ 1,811,113 2,229,749 1.96$ 363.95$Lab and X-Ray 139,965$ 9,325 11,480 15.01$ 14.36$Optical 22,415$ 495 609 45.28$ 2.30$Limited Dental Services 649$ 26 32 24.95$ 0.07$Transportation 521,263$ 32,158 39,592 16.21$ 53.48$Case Management 2,252$ 174 214 12.94$ 0.23$Patient-Centered Medical Home (PCMH) Payments 105,031$ 15,320 18,861 6.86$ 10.78$Subtotal (Covered Services) 56,829,298$ 6,753,171 5,830.44$

Capitation — PACE -$ - - -$ -$Dental 128,325$ 2,266 2,790 56.63$ 13.17$Local Education Agency (LEA) 137,986$ 12,701 15,637 10.86$ 14.16$Children’s Developmental Services Agencies (CDSA) 26,816$ 1,315 1,619 20.39$ 2.75$Subtotal (Excluded Services) 293,127$ 16,282 30.07$Total (All) 57,122,425$ 6,769,453 5,860.51$



SFY 2015

Region 5



Non-Duals

All Ages

9,747812




112 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 3,207,710$ 3,777 5,905 849.20$ 417.89$Inpatient — BH (LME/MCO) 88,784$ 142 223 623.77$ 11.57$Outpatient Hospital 888,315$ 3,317 5,186 267.81$ 115.73$Emergency Room 849,573$ 1,495 2,337 568.28$ 110.68$Physician 1,833,507$ 12,951 20,247 141.57$ 238.86$FQHC/RHC 90,233$ 932 1,457 96.81$ 11.76$Other Clinic 459,613$ 463 724 992.66$ 59.88$Other Practitioner 18,602$ 253 396 73.52$ 2.42$Therapies 203,078$ 1,707 2,669 118.96$ 26.46$Prescribed Drugs 6,467,991$ 58,157 90,918 111.22$ 842.63$Enhanced BH 134,969$ 4,254 6,651 31.73$ 17.58$B3 Services 33,396$ 6,809 10,645 4.90$ 4.35$LTSS – ICF/IID and Nursing Home 12,732,686$ 75,481 118,001 168.69$ 1,658.77$LTSS – State Plan Home and Community Based Services (HCBS) 1,416,986$ 292,477 457,234 4.84$ 184.60$LTSS – HCBS Waiver Services 11,854,198$ 2,640,812 4,128,419 4.49$ 1,544.32$Durable Medical Equipment 2,517,421$ 791,986 1,238,122 3.18$ 327.96$Lab and X-Ray 118,845$ 7,704 12,044 15.43$ 15.48$Optical 20,520$ 430 672 47.72$ 2.67$Limited Dental Services 100$ 4 6 24.90$ 0.01$Transportation 889,753$ 107,248 167,663 8.30$ 115.91$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 75,259$ 10,630 16,618 7.08$ 9.80$Subtotal (Covered Services) 43,901,536$ 4,021,031 5,719.32$

Capitation — PACE -$ - - -$ -$Dental 102,176$ 1,794 2,805 56.95$ 13.31$Local Education Agency (LEA) 52,466$ 1,901 2,972 27.60$ 6.84$Children’s Developmental Services Agencies (CDSA) 14,168$ 670 1,047 21.15$ 1.85$Subtotal (Excluded Services) 168,810$ 4,365 21.99$Total (All) 44,070,346$ 4,025,396 5,741.32$



SFY 2015

Region 6



Non-Duals

All Ages

7,676640




113 of 179



114 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 49,467,669$ 229,441 1,102 215.60$ 19.80$Inpatient — BH (LME/MCO) 1,717,631$ 7,676 37 223.76$ 0.69$Outpatient Hospital 35,265,157$ 404,611 1,943 87.16$ 14.11$Emergency Room 25,254,035$ 264,142 1,269 95.61$ 10.11$Physician 65,751,242$ 2,475,837 11,891 26.56$ 26.32$FQHC/RHC 3,239,505$ 132,791 638 24.40$ 1.30$Other Clinic 5,661,182$ 53,456 257 105.90$ 2.27$Other Practitioner 700,350$ 58,409 281 11.99$ 0.28$Therapies 29,080$ 545 3 53.35$ 0.01$Prescribed Drugs 41,912,720$ 500,598 2,404 83.73$ 16.77$Enhanced BH 10,063,839$ 923,258 4,434 10.90$ 4.03$B3 Services 547,624$ 73,364 352 7.46$ 0.22$LTSS – ICF/IID and Nursing Home 671,072,232$ 4,911,358 23,588 136.64$ 268.58$LTSS – State Plan Home and Community Based Services (HCBS) 357,222,724$ 93,624,843 449,652 3.82$ 142.97$LTSS – HCBS Waiver Services 196,264,922$ 60,919,206 292,577 3.22$ 78.55$Durable Medical Equipment 35,307,335$ 25,374,969 121,868 1.39$ 14.13$Lab and X-Ray 1,440,549$ 131,104 630 10.99$ 0.58$Optical 854,169$ 114,405 549 7.47$ 0.34$Limited Dental Services 50$ 3 0 16.70$ 0.00$Transportation 28,344,237$ 2,470,256 11,864 11.47$ 11.34$Case Management 550,474$ 42,667 205 12.90$ 0.22$Patient-Centered Medical Home (PCMH) Payments 27,807,845$ 3,277,559 15,741 8.48$ 11.13$Subtotal (Covered Services) 1,558,474,569$ 195,990,500 623.74$

Capitation — PACE 26,829,164$ 9,071 44 2,957.69$ 10.74$Dental 31,696,025$ 473,195 2,273 66.98$ 12.69$Local Education Agency (LEA) 2,462$ 102 0 24.13$ 0.00$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 58,527,650$ 482,368 23.42$Total (All) 1,617,002,219$ 196,472,868 647.16$



SFY 2015

Statewide

Dual Eligibles


Duals

All Ages

2,498,594208,216




115 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,917,623$ 23,256 931 211.46$ 16.41$Inpatient — BH (LME/MCO) 295,980$ 450 18 657.31$ 0.99$Outpatient Hospital 5,867,795$ 55,167 2,210 106.36$ 19.59$Emergency Room 4,264,868$ 30,139 1,207 141.51$ 14.24$Physician 6,154,612$ 278,605 11,159 22.09$ 20.54$FQHC/RHC 581,987$ 23,700 949 24.56$ 1.94$Other Clinic 245,529$ 2,879 115 85.28$ 0.82$Other Practitioner 81,117$ 7,530 302 10.77$ 0.27$Therapies 5,840$ 89 4 65.62$ 0.02$Prescribed Drugs 4,816,758$ 61,165 2,450 78.75$ 16.08$Enhanced BH 1,335,552$ 74,931 3,001 17.82$ 4.46$B3 Services 139,984$ 10,751 431 13.02$ 0.47$LTSS – ICF/IID and Nursing Home 105,419,702$ 754,605 30,224 139.70$ 351.86$LTSS – State Plan Home and Community Based Services (HCBS) 24,713,978$ 5,878,255 235,441 4.20$ 82.49$LTSS – HCBS Waiver Services 31,085,388$ 9,429,456 377,677 3.30$ 103.75$Durable Medical Equipment 3,040,937$ 2,058,461 82,447 1.48$ 10.15$Lab and X-Ray 164,037$ 15,591 624 10.52$ 0.55$Optical 68,606$ 8,462 339 8.11$ 0.23$Limited Dental Services -$ - - -$ -$Transportation 2,336,070$ 159,597 6,392 14.64$ 7.80$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 3,044,198$ 358,864 14,374 8.48$ 10.16$Subtotal (Covered Services) 198,580,561$ 19,231,952 662.81$




SFY 2015

Region 1

Dual Eligibles


Duals

All Ages

299,60424,967




116 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 8,779,053$ 34,140 978 257.15$ 20.95$Inpatient — BH (LME/MCO) 294,678$ 1,618 46 182.09$ 0.70$Outpatient Hospital 5,921,528$ 89,592 2,566 66.09$ 14.13$Emergency Room 3,677,051$ 41,855 1,199 87.85$ 8.77$Physician 15,927,281$ 366,902 10,507 43.41$ 38.01$FQHC/RHC 126,506$ 4,758 136 26.59$ 0.30$Other Clinic 1,118,739$ 8,203 235 136.38$ 2.67$Other Practitioner 85,275$ 7,739 222 11.02$ 0.20$Therapies 6,794$ 241 7 28.19$ 0.02$Prescribed Drugs 7,581,917$ 92,542 2,650 81.93$ 18.09$Enhanced BH 1,432,476$ 135,868 3,891 10.54$ 3.42$B3 Services 45,082$ 7,836 224 5.75$ 0.11$LTSS – ICF/IID and Nursing Home 111,702,396$ 842,140 24,116 132.64$ 266.57$LTSS – State Plan Home and Community Based Services (HCBS) 54,758,030$ 14,003,558 401,019 3.91$ 130.68$LTSS – HCBS Waiver Services 35,839,045$ 11,116,656 318,347 3.22$ 85.53$Durable Medical Equipment 4,719,393$ 3,694,131 105,789 1.28$ 11.26$Lab and X-Ray 256,252$ 22,994 658 11.14$ 0.61$Optical 90,560$ 13,761 394 6.58$ 0.22$Limited Dental Services 0$ 1 0 0.31$ 0.00$Transportation 4,955,137$ 302,090 8,651 16.40$ 11.83$Case Management 55,360$ 4,293 123 12.90$ 0.13$Patient-Centered Medical Home (PCMH) Payments 4,575,056$ 546,074 15,638 8.38$ 10.92$Subtotal (Covered Services) 261,947,609$ 31,336,991 625.12$




SFY 2015

Region 2

Dual Eligibles


Duals

All Ages

419,03934,920




117 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 8,763,871$ 49,134 1,230 178.37$ 18.29$Inpatient — BH (LME/MCO) 307,717$ 1,661 42 185.24$ 0.64$Outpatient Hospital 6,619,123$ 85,458 2,140 77.45$ 13.81$Emergency Room 4,596,390$ 51,510 1,290 89.23$ 9.59$Physician 11,862,617$ 491,945 12,317 24.11$ 24.75$FQHC/RHC 280,067$ 12,609 316 22.21$ 0.58$Other Clinic 1,187,520$ 10,058 252 118.06$ 2.48$Other Practitioner 134,293$ 12,021 301 11.17$ 0.28$Therapies 2,251$ 79 2 28.49$ 0.00$Prescribed Drugs 8,760,892$ 99,235 2,485 88.28$ 18.28$Enhanced BH 1,985,308$ 187,813 4,702 10.57$ 4.14$B3 Services 71,954$ 7,655 192 9.40$ 0.15$LTSS – ICF/IID and Nursing Home 119,089,982$ 891,342 22,317 133.61$ 248.48$LTSS – State Plan Home and Community Based Services (HCBS) 75,742,381$ 19,527,108 488,908 3.88$ 158.03$LTSS – HCBS Waiver Services 35,010,078$ 10,805,750 270,548 3.24$ 73.05$Durable Medical Equipment 6,071,757$ 4,792,947 120,003 1.27$ 12.67$Lab and X-Ray 319,437$ 27,354 685 11.68$ 0.67$Optical 107,331$ 13,988 350 7.67$ 0.22$Limited Dental Services -$ - - -$ -$Transportation 4,471,316$ 154,723 3,874 28.90$ 9.33$Case Management 159,786$ 12,384 310 12.90$ 0.33$Patient-Centered Medical Home (PCMH) Payments 5,395,915$ 627,957 15,722 8.59$ 11.26$Subtotal (Covered Services) 290,939,987$ 37,862,731 607.03$

Capitation — PACE 6,882,737$ 2,188 55 3,145.67$ 14.36$Dental 6,535,926$ 95,544 2,392 68.41$ 13.64$Local Education Agency (LEA) 2,412$ 100 3 24.12$ 0.01$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 13,421,075$ 97,832 28.00$Total (All) 304,361,062$ 37,960,563 635.03$



SFY 2015

Region 3

Dual Eligibles


Duals

All Ages

479,28339,940




118 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 8,519,480$ 40,831 1,116 208.65$ 19.41$Inpatient — BH (LME/MCO) 338,601$ 1,365 37 248.07$ 0.77$Outpatient Hospital 6,361,397$ 66,213 1,810 96.07$ 14.49$Emergency Room 3,981,381$ 43,566 1,191 91.39$ 9.07$Physician 10,120,133$ 408,209 11,160 24.79$ 23.06$FQHC/RHC 637,206$ 23,374 639 27.26$ 1.45$Other Clinic 1,148,414$ 11,841 324 96.98$ 2.62$Other Practitioner 112,969$ 7,301 200 15.47$ 0.26$Therapies 6,157$ 45 1 136.81$ 0.01$Prescribed Drugs 6,685,807$ 80,237 2,194 83.33$ 15.23$Enhanced BH 2,610,835$ 224,641 6,142 11.62$ 5.95$B3 Services 95,507$ 12,496 342 7.64$ 0.22$LTSS – ICF/IID and Nursing Home 113,029,347$ 810,764 22,166 139.41$ 257.51$LTSS – State Plan Home and Community Based Services (HCBS) 67,800,744$ 18,106,047 495,004 3.74$ 154.47$LTSS – HCBS Waiver Services 24,095,897$ 7,510,742 205,337 3.21$ 54.90$Durable Medical Equipment 6,248,250$ 5,241,651 143,302 1.19$ 14.24$Lab and X-Ray 243,436$ 22,529 616 10.81$ 0.55$Optical 141,693$ 17,068 467 8.30$ 0.32$Limited Dental Services -$ - - -$ -$Transportation 4,784,224$ 347,535 9,501 13.77$ 10.90$Case Management 146,891$ 11,391 311 12.90$ 0.33$Patient-Centered Medical Home (PCMH) Payments 4,461,643$ 534,443 14,611 8.35$ 10.16$Subtotal (Covered Services) 261,570,011$ 33,522,290 595.93$

Capitation — PACE 2,819,757$ 868 24 3,248.57$ 6.42$Dental 5,817,607$ 89,899 2,458 64.71$ 13.25$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 8,637,364$ 90,767 19.68$Total (All) 270,207,375$ 33,613,057 615.60$



SFY 2015

Region 4

Dual Eligibles


Duals

All Ages

438,93136,578




119 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 10,963,224$ 47,227 1,282 232.14$ 24.80$Inpatient — BH (LME/MCO) 196,231$ 725 20 270.84$ 0.44$Outpatient Hospital 5,541,235$ 63,033 1,711 87.91$ 12.54$Emergency Room 4,309,457$ 48,456 1,316 88.93$ 9.75$Physician 12,119,216$ 506,720 13,757 23.92$ 27.42$FQHC/RHC 848,921$ 32,216 875 26.35$ 1.92$Other Clinic 1,022,370$ 10,572 287 96.70$ 2.31$Other Practitioner 143,806$ 12,022 326 11.96$ 0.33$Therapies 4,887$ 54 1 90.49$ 0.01$Prescribed Drugs 8,182,126$ 92,924 2,523 88.05$ 18.51$Enhanced BH 1,484,704$ 144,588 3,925 10.27$ 3.36$B3 Services 122,560$ 22,599 614 5.42$ 0.28$LTSS – ICF/IID and Nursing Home 109,934,202$ 791,903 21,499 138.82$ 248.71$LTSS – State Plan Home and Community Based Services (HCBS) 70,350,771$ 18,682,667 507,207 3.77$ 159.16$LTSS – HCBS Waiver Services 37,731,634$ 12,076,627 327,863 3.12$ 85.36$Durable Medical Equipment 5,890,919$ 5,039,051 136,803 1.17$ 13.33$Lab and X-Ray 265,405$ 25,356 688 10.47$ 0.60$Optical 242,973$ 36,598 994 6.64$ 0.55$Limited Dental Services 50$ 2 0 24.90$ 0.00$Transportation 4,846,202$ 385,628 10,469 12.57$ 10.96$Case Management 161,910$ 12,535 340 12.92$ 0.37$Patient-Centered Medical Home (PCMH) Payments 5,095,704$ 593,688 16,118 8.58$ 11.53$Subtotal (Covered Services) 279,458,509$ 38,625,192 632.24$

Capitation — PACE 9,454,967$ 2,950 80 3,205.07$ 21.39$Dental 5,966,443$ 88,862 2,412 67.14$ 13.50$Local Education Agency (LEA) 49$ 2 0 24.59$ 0.00$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 15,421,459$ 91,814 34.89$Total (All) 294,879,968$ 38,717,006 667.13$



SFY 2015

Region 5

Dual Eligibles


Duals

All Ages

442,01336,834




120 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 7,524,418$ 34,853 996 215.89$ 17.93$Inpatient — BH (LME/MCO) 284,424$ 1,857 53 153.16$ 0.68$Outpatient Hospital 4,954,080$ 45,148 1,291 109.73$ 11.80$Emergency Room 4,424,888$ 48,617 1,390 91.01$ 10.54$Physician 9,567,382$ 423,457 12,107 22.59$ 22.79$FQHC/RHC 764,819$ 36,134 1,033 21.17$ 1.82$Other Clinic 938,610$ 9,901 283 94.80$ 2.24$Other Practitioner 142,889$ 11,794 337 12.11$ 0.34$Therapies 3,152$ 37 1 85.18$ 0.01$Prescribed Drugs 5,885,219$ 74,495 2,130 79.00$ 14.02$Enhanced BH 1,214,964$ 155,416 4,443 7.82$ 2.89$B3 Services 72,536$ 12,027 344 6.03$ 0.17$LTSS – ICF/IID and Nursing Home 111,896,603$ 820,604 23,461 136.36$ 266.60$LTSS – State Plan Home and Community Based Services (HCBS) 63,856,820$ 17,427,208 498,248 3.66$ 152.14$LTSS – HCBS Waiver Services 32,502,880$ 9,979,976 285,330 3.26$ 77.44$Durable Medical Equipment 9,336,080$ 4,548,728 130,049 2.05$ 22.24$Lab and X-Ray 191,982$ 17,280 494 11.11$ 0.46$Optical 203,005$ 24,528 701 8.28$ 0.48$Limited Dental Services -$ - - -$ -$Transportation 6,951,288$ 1,120,682 32,041 6.20$ 16.56$Case Management 26,527$ 2,064 59 12.85$ 0.06$Patient-Centered Medical Home (PCMH) Payments 5,235,329$ 616,533 17,627 8.49$ 12.47$Subtotal (Covered Services) 265,977,892$ 35,411,343 633.70$

Capitation — PACE 3,351$ 2 0 1,675.44$ 0.01$Dental 4,959,349$ 76,115 2,176 65.16$ 11.82$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 4,962,700$ 76,117 11.82$Total (All) 270,940,592$ 35,487,460 645.52$



SFY 2015

Region 6

Dual Eligibles


Duals

All Ages

419,72434,977




121 of 179


SFY 2016 Regional Exhibits8.2Cost and utilization information for the July 1, 2015 through June 30, 2016 (SFY 2016) time period is illustrated inSection 8.2.

122 of 179



123 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 650,321,532$ 812,000 533 800.89$ 35.54$Inpatient — BH (LME/MCO) 26,031,559$ 40,208 26 647.42$ 1.42$Outpatient Hospital 401,226,668$ 1,278,167 838 313.91$ 21.93$Emergency Room 443,877,677$ 1,232,943 809 360.01$ 24.26$Physician 731,214,458$ 7,093,622 4,652 103.08$ 39.96$FQHC/RHC 46,415,075$ 419,043 275 110.76$ 2.54$Other Clinic 156,652,142$ 1,260,917 827 124.24$ 8.56$Other Practitioner 4,400,630$ 61,099 40 72.02$ 0.24$Therapies 58,581,508$ 527,885 346 110.97$ 3.20$Prescribed Drugs 1,371,151,245$ 12,765,734 8,372 107.41$ 74.93$Enhanced BH 114,525,741$ 1,703,622 1,117 67.22$ 6.26$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 1,872,069$ 12,201 8 153.44$ 0.10$LTSS – State Plan Home and Community Based Services (HCBS) 118,642,110$ 23,418,207 15,357 5.07$ 6.48$LTSS – HCBS Waiver Services 127,891$ 38,762 25 3.30$ 0.01$Durable Medical Equipment 99,379,994$ 34,042,281 22,325 2.92$ 5.43$Lab and X-Ray 77,360,886$ 4,080,633 2,676 18.96$ 4.23$Optical 23,210,944$ 1,068,804 701 21.72$ 1.27$Limited Dental Services 6,904,401$ 277,308 182 24.90$ 0.38$Transportation 36,370,438$ 1,142,370 749 31.84$ 1.99$Case Management 641,087$ 49,591 33 12.93$ 0.04$Patient-Centered Medical Home (PCMH) Payments 153,535,460$ 50,284,579 32,976 3.05$ 8.39$Subtotal (Covered Services) 4,522,443,516$ 141,609,975 247.15$

Capitation — PACE 3,838,292$ 24,127 16 159.09$ 0.21$Dental 322,019,655$ 6,990,958 4,585 46.06$ 17.60$Local Education Agency (LEA) 12,414,277$ 383,307 251 32.39$ 0.68$Children’s Developmental Services Agencies (CDSA) 1,932,004$ 70,501 46 27.40$ 0.11$Subtotal (Excluded Services) 340,204,228$ 7,468,893 18.59$Total (All) 4,862,647,744$ 149,078,869 265.74$



SFY 2016

Statewide

Standard Plan


Non-Duals

All Ages

18,298,5551,524,880




124 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 61,456,651$ 74,289 519 827.26$ 35.81$Inpatient — BH (LME/MCO) 3,095,913$ 3,740 26 827.68$ 1.80$Outpatient Hospital 55,568,402$ 199,582 1,395 278.42$ 32.38$Emergency Room 40,152,656$ 108,532 759 369.96$ 23.39$Physician 69,379,137$ 722,156 5,049 96.07$ 40.42$FQHC/RHC 9,848,245$ 72,623 508 135.61$ 5.74$Other Clinic 13,437,026$ 116,290 813 115.55$ 7.83$Other Practitioner 564,688$ 9,337 65 60.48$ 0.33$Therapies 4,597,323$ 45,755 320 100.48$ 2.68$Prescribed Drugs 137,620,197$ 1,368,931 9,571 100.53$ 80.18$Enhanced BH 12,959,870$ 178,092 1,245 72.77$ 7.55$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 252,544$ 1,621 11 155.80$ 0.15$LTSS – State Plan Home and Community Based Services (HCBS) 6,660,017$ 843,320 5,896 7.90$ 3.88$LTSS – HCBS Waiver Services 4,205$ 581 4 7.24$ 0.00$Durable Medical Equipment 10,377,705$ 3,437,629 24,035 3.02$ 6.05$Lab and X-Ray 5,255,840$ 265,216 1,854 19.82$ 3.06$Optical 2,001,445$ 97,424 681 20.54$ 1.17$Limited Dental Services 497,600$ 20,046 140 24.82$ 0.29$Transportation 3,470,743$ 131,821 922 26.33$ 2.02$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 14,226,576$ 4,674,187 32,681 3.04$ 8.29$Subtotal (Covered Services) 451,426,785$ 12,371,173 263.02$

Capitation — PACE 1,485,666$ 19,663 137 75.56$ 0.87$Dental 29,370,393$ 620,925 4,341 47.30$ 17.11$Local Education Agency (LEA) 1,793,716$ 55,394 387 32.38$ 1.05$Children’s Developmental Services Agencies (CDSA) 201,336$ 7,160 50 28.12$ 0.12$Subtotal (Excluded Services) 32,851,112$ 703,142 19.14$Total (All) 484,277,896$ 13,074,315 282.16$



SFY 2016

Region 1

Standard Plan


Non-Duals

All Ages

1,716,313143,026




125 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 108,125,328$ 130,334 506 829.60$ 35.00$Inpatient — BH (LME/MCO) 4,490,347$ 6,936 27 647.41$ 1.45$Outpatient Hospital 75,308,960$ 253,954 986 296.55$ 24.38$Emergency Room 76,760,718$ 203,116 789 377.92$ 24.85$Physician 119,879,349$ 1,227,412 4,767 97.67$ 38.80$FQHC/RHC 4,325,414$ 39,185 152 110.38$ 1.40$Other Clinic 25,649,651$ 207,088 804 123.86$ 8.30$Other Practitioner 661,378$ 8,977 35 73.67$ 0.21$Therapies 7,093,304$ 58,594 228 121.06$ 2.30$Prescribed Drugs 236,498,533$ 2,214,316 8,601 106.80$ 76.55$Enhanced BH 17,157,702$ 252,215 980 68.03$ 5.55$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 358,190$ 2,413 9 148.47$ 0.12$LTSS – State Plan Home and Community Based Services (HCBS) 18,212,354$ 3,338,824 12,969 5.45$ 5.89$LTSS – HCBS Waiver Services 4,940$ 1,091 4 4.53$ 0.00$Durable Medical Equipment 17,410,187$ 5,713,510 22,192 3.05$ 5.64$Lab and X-Ray 15,393,242$ 813,549 3,160 18.92$ 4.98$Optical 3,867,776$ 183,766 714 21.05$ 1.25$Limited Dental Services 1,310,316$ 52,446 204 24.98$ 0.42$Transportation 5,621,876$ 126,829 493 44.33$ 1.82$Case Management 64,482$ 4,984 19 12.94$ 0.02$Patient-Centered Medical Home (PCMH) Payments 26,314,372$ 8,654,630 33,616 3.04$ 8.52$Subtotal (Covered Services) 764,508,416$ 23,494,170 247.46$

Capitation — PACE 1,042,520$ 2,905 11 358.83$ 0.34$Dental 56,383,324$ 1,239,832 4,816 45.48$ 18.25$Local Education Agency (LEA) 2,465,689$ 76,353 297 32.29$ 0.80$Children’s Developmental Services Agencies (CDSA) 385,080$ 14,980 58 25.71$ 0.12$Subtotal (Excluded Services) 60,276,613$ 1,334,071 19.51$Total (All) 824,785,029$ 24,828,240 266.97$



SFY 2016

Region 2

Standard Plan


Non-Duals

All Ages

3,089,459257,455




126 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 139,985,221$ 186,812 512 749.34$ 31.96$Inpatient — BH (LME/MCO) 5,738,091$ 9,925 27 578.17$ 1.31$Outpatient Hospital 91,396,596$ 299,940 822 304.72$ 20.87$Emergency Room 110,355,268$ 292,952 803 376.70$ 25.19$Physician 174,912,716$ 1,732,200 4,745 100.98$ 39.93$FQHC/RHC 4,157,173$ 38,552 106 107.83$ 0.95$Other Clinic 36,097,870$ 299,514 821 120.52$ 8.24$Other Practitioner 1,225,637$ 16,987 47 72.15$ 0.28$Therapies 9,850,529$ 93,377 256 105.49$ 2.25$Prescribed Drugs 317,243,586$ 2,915,567 7,987 108.81$ 72.43$Enhanced BH 26,500,530$ 429,684 1,177 61.67$ 6.05$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 568,206$ 3,658 10 155.31$ 0.13$LTSS – State Plan Home and Community Based Services (HCBS) 33,335,723$ 6,599,030 18,078 5.05$ 7.61$LTSS – HCBS Waiver Services 12,796$ 3,319 9 3.86$ 0.00$Durable Medical Equipment 25,423,636$ 7,415,518 20,315 3.43$ 5.80$Lab and X-Ray 17,737,025$ 913,592 2,503 19.41$ 4.05$Optical 3,881,726$ 208,391 571 18.63$ 0.89$Limited Dental Services 1,366,673$ 54,883 150 24.90$ 0.31$Transportation 7,748,006$ 159,432 437 48.60$ 1.77$Case Management 190,397$ 14,729 40 12.93$ 0.04$Patient-Centered Medical Home (PCMH) Payments 36,107,814$ 11,960,455 32,766 3.02$ 8.24$Subtotal (Covered Services) 1,043,835,219$ 33,648,518 238.30$

Capitation — PACE 445,501$ 1,230 3 362.16$ 0.10$Dental 79,016,623$ 1,731,324 4,743 45.64$ 18.04$Local Education Agency (LEA) 2,939,279$ 92,959 255 31.62$ 0.67$Children’s Developmental Services Agencies (CDSA) 496,820$ 17,676 48 28.11$ 0.11$Subtotal (Excluded Services) 82,898,223$ 1,843,190 18.93$Total (All) 1,126,733,442$ 35,491,708 257.23$



SFY 2016

Region 3

Standard Plan


Non-Duals

All Ages

4,380,303365,025




127 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM





SFY 2016

Region 4

Standard Plan


Non-Duals

All Ages

3,518,590293,216




128 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM





SFY 2016

Region 5

Standard Plan


Non-Duals

All Ages

3,116,026259,669




129 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 96,433,538$ 111,974 542 861.22$ 38.92$Inpatient — BH (LME/MCO) 4,420,689$ 6,778 33 652.25$ 1.78$Outpatient Hospital 44,838,304$ 120,572 584 371.88$ 18.10$Emergency Room 64,515,443$ 184,693 894 349.31$ 26.04$Physician 96,135,233$ 905,299 4,384 106.19$ 38.80$FQHC/RHC 8,822,242$ 83,137 403 106.12$ 3.56$Other Clinic 24,527,918$ 180,155 872 136.15$ 9.90$Other Practitioner 619,319$ 8,429 41 73.48$ 0.25$Therapies 6,897,809$ 59,801 290 115.35$ 2.78$Prescribed Drugs 195,859,905$ 1,808,095 8,756 108.32$ 79.04$Enhanced BH 13,465,740$ 207,023 1,003 65.04$ 5.43$B3 Services -$ - - -$ -$LTSS – ICF/IID and Nursing Home 220,242$ 1,440 7 152.95$ 0.09$LTSS – State Plan Home and Community Based Services (HCBS) 18,527,281$ 3,710,670 17,970 4.99$ 7.48$LTSS – HCBS Waiver Services 51,322$ 13,558 66 3.79$ 0.02$Durable Medical Equipment 14,373,325$ 5,026,058 24,341 2.86$ 5.80$Lab and X-Ray 10,438,905$ 544,240 2,636 19.18$ 4.21$Optical 3,767,306$ 159,722 774 23.59$ 1.52$Limited Dental Services 1,147,587$ 46,128 223 24.88$ 0.46$Transportation 6,242,114$ 336,547 1,630 18.55$ 2.52$Case Management 31,910$ 2,472 12 12.91$ 0.01$Patient-Centered Medical Home (PCMH) Payments 21,513,393$ 6,881,118 33,324 3.13$ 8.68$Subtotal (Covered Services) 632,849,525$ 20,397,909 255.40$

Capitation — PACE 844$ 22 0 38.37$ 0.00$Dental 36,539,310$ 803,957 3,893 45.45$ 14.75$Local Education Agency (LEA) 1,295,326$ 41,162 199 31.47$ 0.52$Children’s Developmental Services Agencies (CDSA) 208,158$ 7,461 36 27.90$ 0.08$Subtotal (Excluded Services) 38,043,638$ 852,601 15.35$Total (All) 670,893,163$ 21,250,510 270.75$



SFY 2016

Region 6

Standard Plan


Non-Duals

All Ages

2,477,864206,489




130 of 179



131 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,980,520$ 4,836 215 1,029.79$ 18.42$Inpatient — BH (LME/MCO) 10,182,319$ 14,171 629 718.54$ 37.66$Outpatient Hospital 4,725,905$ 18,055 801 261.74$ 17.48$Emergency Room 4,579,305$ 13,767 611 332.63$ 16.94$Physician 8,748,325$ 108,241 4,804 80.82$ 32.35$FQHC/RHC 597,300$ 5,061 225 118.03$ 2.21$Other Clinic 2,342,739$ 21,970 975 106.63$ 8.66$Other Practitioner 49,929$ 708 31 70.54$ 0.18$Therapies 4,915,908$ 43,713 1,940 112.46$ 18.18$Prescribed Drugs 39,013,211$ 279,722 12,414 139.47$ 144.28$Enhanced BH 116,291,772$ 1,013,686 44,986 114.72$ 430.07$B3 Services 385,764$ 62,412 2,770 6.18$ 1.43$LTSS – ICF/IID and Nursing Home 1,701,447$ 24,262 1,077 70.13$ 6.29$LTSS – State Plan Home and Community Based Services (HCBS) 838,585$ 127,094 5,640 6.60$ 3.10$LTSS – HCBS Waiver Services 1,448,670$ 207,310 9,200 6.99$ 5.36$Durable Medical Equipment 2,110,942$ 928,201 41,192 2.27$ 7.81$Lab and X-Ray 1,093,583$ 56,881 2,524 19.23$ 4.04$Optical 595,374$ 28,458 1,263 20.92$ 2.20$Limited Dental Services 112,349$ 4,498 200 24.98$ 0.42$Transportation 663,183$ 10,499 466 63.16$ 2.45$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,957,927$ 784,728 34,825 2.50$ 7.24$Subtotal (Covered Services) 207,335,058$ 3,758,273 766.77$




SFY 2016

Statewide



Non-Duals

All Ages

270,40222,534




132 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 449,643$ 488 137 922.22$ 10.51$Inpatient — BH (LME/MCO) 1,568,760$ 1,676 470 936.23$ 36.67$Outpatient Hospital 1,113,857$ 5,055 1,418 220.34$ 26.04$Emergency Room 633,540$ 1,884 528 336.28$ 14.81$Physician 1,492,430$ 19,024 5,337 78.45$ 34.89$FQHC/RHC 258,560$ 1,845 518 140.15$ 6.04$Other Clinic 345,376$ 3,352 940 103.04$ 8.07$Other Practitioner 13,357$ 218 61 61.20$ 0.31$Therapies 810,008$ 7,584 2,127 106.81$ 18.94$Prescribed Drugs 6,222,874$ 47,863 13,426 130.01$ 145.47$Enhanced BH 20,710,099$ 195,312 54,789 106.04$ 484.13$B3 Services 68,479$ 6,880 1,930 9.95$ 1.60$LTSS – ICF/IID and Nursing Home 103,717$ 1,219 342 85.12$ 2.42$LTSS – State Plan Home and Community Based Services (HCBS) 212,131$ 25,302 7,098 8.38$ 4.96$LTSS – HCBS Waiver Services 413,018$ 37,869 10,623 10.91$ 9.65$Durable Medical Equipment 277,469$ 112,673 31,607 2.46$ 6.49$Lab and X-Ray 87,317$ 4,752 1,333 18.38$ 2.04$Optical 89,320$ 4,465 1,252 20.01$ 2.09$Limited Dental Services 15,620$ 629 177 24.82$ 0.37$Transportation 107,603$ 2,110 592 51.00$ 2.52$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 314,414$ 126,291 35,427 2.49$ 7.35$Subtotal (Covered Services) 35,307,590$ 606,489 825.37$

Capitation — PACE 146,580$ 141 40 1,039.48$ 3.43$Dental 1,034,230$ 22,972 6,444 45.02$ 24.18$Local Education Agency (LEA) 120,865$ 3,672 1,030 32.91$ 2.83$Children’s Developmental Services Agencies (CDSA) 273,623$ 11,070 3,105 24.72$ 6.40$Subtotal (Excluded Services) 1,575,298$ 37,856 36.82$Total (All) 36,882,888$ 644,346 862.19$



SFY 2016

Region 1



Non-Duals

All Ages

42,7783,565




133 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,042,655$ 1,143 306 912.26$ 23.24$Inpatient — BH (LME/MCO) 999,742$ 1,629 436 613.56$ 22.29$Outpatient Hospital 908,045$ 3,382 905 268.48$ 20.24$Emergency Room 822,530$ 2,219 594 370.71$ 18.34$Physician 1,524,938$ 19,295 5,161 79.03$ 33.99$FQHC/RHC 79,047$ 680 182 116.24$ 1.76$Other Clinic 386,756$ 3,592 961 107.67$ 8.62$Other Practitioner 8,772$ 79 21 110.88$ 0.20$Therapies 711,933$ 5,861 1,568 121.46$ 15.87$Prescribed Drugs 6,474,410$ 47,760 12,776 135.56$ 144.32$Enhanced BH 14,799,192$ 126,932 33,954 116.59$ 329.90$B3 Services 61,060$ 6,561 1,755 9.31$ 1.36$LTSS – ICF/IID and Nursing Home 394,652$ 5,506 1,473 71.67$ 8.80$LTSS – State Plan Home and Community Based Services (HCBS) 31,336$ 9,011 2,411 3.48$ 0.70$LTSS – HCBS Waiver Services 104,424$ 19,316 5,167 5.41$ 2.33$Durable Medical Equipment 298,038$ 178,341 47,706 1.67$ 6.64$Lab and X-Ray 188,389$ 10,209 2,731 18.45$ 4.20$Optical 87,229$ 4,198 1,123 20.78$ 1.94$Limited Dental Services 20,680$ 817 219 25.30$ 0.46$Transportation 101,225$ 1,541 412 65.71$ 2.26$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 337,915$ 134,174 35,891 2.52$ 7.53$Subtotal (Covered Services) 29,382,968$ 582,247 654.99$

Capitation — PACE 12,485$ 22 6 567.45$ 0.28$Dental 993,823$ 23,736 6,349 41.87$ 22.15$Local Education Agency (LEA) 95,749$ 2,945 788 32.51$ 2.13$Children’s Developmental Services Agencies (CDSA) 129,788$ 5,166 1,382 25.13$ 2.89$Subtotal (Excluded Services) 1,231,845$ 31,869 27.46$Total (All) 30,614,813$ 614,116 682.45$



SFY 2016

Region 2



Non-Duals

All Ages

44,8603,738




134 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 955,848$ 905 185 1,056.73$ 16.28$Inpatient — BH (LME/MCO) 1,916,729$ 2,954 604 648.95$ 32.64$Outpatient Hospital 1,026,284$ 3,463 708 296.33$ 17.48$Emergency Room 1,266,919$ 3,286 671 385.54$ 21.57$Physician 1,780,451$ 22,366 4,570 79.60$ 30.32$FQHC/RHC 47,259$ 434 89 108.99$ 0.80$Other Clinic 478,316$ 4,560 932 104.89$ 8.14$Other Practitioner 12,311$ 206 42 59.69$ 0.21$Therapies 1,007,772$ 8,932 1,825 112.83$ 17.16$Prescribed Drugs 7,656,671$ 59,252 12,107 129.22$ 130.38$Enhanced BH 23,313,516$ 210,456 43,004 110.78$ 396.98$B3 Services 144,645$ 28,527 5,829 5.07$ 2.46$LTSS – ICF/IID and Nursing Home 358,822$ 9,031 1,845 39.73$ 6.11$LTSS – State Plan Home and Community Based Services (HCBS) 358,994$ 62,678 12,807 5.73$ 6.11$LTSS – HCBS Waiver Services 539,568$ 78,855 16,113 6.84$ 9.19$Durable Medical Equipment 618,257$ 189,886 38,800 3.26$ 10.53$Lab and X-Ray 299,014$ 13,832 2,826 21.62$ 5.09$Optical 102,217$ 5,523 1,129 18.51$ 1.74$Limited Dental Services 16,247$ 652 133 24.91$ 0.28$Transportation 142,328$ 2,056 420 69.22$ 2.42$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 452,970$ 178,559 36,486 2.54$ 7.71$Subtotal (Covered Services) 42,495,136$ 886,412 723.60$

Capitation — PACE 11,241$ 19 4 591.56$ 0.19$Dental 1,309,438$ 31,646 6,466 41.38$ 22.30$Local Education Agency (LEA) 160,354$ 5,135 1,049 31.23$ 2.73$Children’s Developmental Services Agencies (CDSA) 242,846$ 9,488 1,939 25.59$ 4.14$Subtotal (Excluded Services) 1,723,879$ 46,288 29.35$Total (All) 44,219,014$ 932,701 752.96$



SFY 2016

Region 3



Non-Duals

All Ages

58,7274,894




135 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 796,935$ 838 201 951.26$ 15.96$Inpatient — BH (LME/MCO) 3,723,101$ 4,675 1,124 796.31$ 74.58$Outpatient Hospital 706,866$ 2,567 617 275.41$ 14.16$Emergency Room 759,971$ 2,347 564 323.86$ 15.22$Physician 1,527,295$ 18,257 4,388 83.66$ 30.59$FQHC/RHC 81,001$ 759 182 106.70$ 1.62$Other Clinic 426,393$ 3,873 931 110.09$ 8.54$Other Practitioner 5,809$ 87 21 66.70$ 0.12$Therapies 967,550$ 8,394 2,018 115.27$ 19.38$Prescribed Drugs 6,578,837$ 47,490 11,415 138.53$ 131.78$Enhanced BH 24,175,860$ 198,612 47,740 121.72$ 484.26$B3 Services 68,074$ 11,470 2,757 5.93$ 1.36$LTSS – ICF/IID and Nursing Home 448,435$ 4,439 1,067 101.03$ 8.98$LTSS – State Plan Home and Community Based Services (HCBS) 89,797$ 14,196 3,412 6.33$ 1.80$LTSS – HCBS Waiver Services 244,174$ 38,435 9,239 6.35$ 4.89$Durable Medical Equipment 414,493$ 214,210 51,490 1.93$ 8.30$Lab and X-Ray 198,422$ 10,834 2,604 18.31$ 3.97$Optical 115,999$ 5,399 1,298 21.48$ 2.32$Limited Dental Services 15,015$ 603 145 24.89$ 0.30$Transportation 120,936$ 1,509 363 80.13$ 2.42$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 336,987$ 137,240 32,988 2.46$ 6.75$Subtotal (Covered Services) 41,801,951$ 726,234 837.33$

Capitation — PACE -$ - - -$ -$Dental 1,137,247$ 26,335 6,330 43.18$ 22.78$Local Education Agency (LEA) 97,911$ 3,090 743 31.68$ 1.96$Children’s Developmental Services Agencies (CDSA) 103,889$ 3,958 951 26.25$ 2.08$Subtotal (Excluded Services) 1,339,048$ 33,383 26.82$Total (All) 43,140,999$ 759,617 864.15$



SFY 2016

Region 4



Non-Duals

All Ages

49,9234,160




136 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,244,562$ 910 235 1,367.82$ 26.78$Inpatient — BH (LME/MCO) 1,095,645$ 1,933 499 566.90$ 23.57$Outpatient Hospital 567,845$ 2,263 584 250.88$ 12.22$Emergency Room 687,575$ 2,603 672 264.11$ 14.79$Physician 1,556,920$ 18,565 4,793 83.86$ 33.50$FQHC/RHC 85,107$ 877 226 97.01$ 1.83$Other Clinic 433,095$ 4,179 1,079 103.64$ 9.32$Other Practitioner 4,354$ 54 14 80.55$ 0.09$Therapies 982,883$ 9,283 2,397 105.88$ 21.15$Prescribed Drugs 7,377,106$ 47,082 12,155 156.69$ 158.72$Enhanced BH 20,971,020$ 175,964 45,430 119.18$ 451.18$B3 Services 17,959$ 3,863 997 4.65$ 0.39$LTSS – ICF/IID and Nursing Home 189,881$ 1,966 507 96.60$ 4.09$LTSS – State Plan Home and Community Based Services (HCBS) 45,073$ 8,624 2,227 5.23$ 0.97$LTSS – HCBS Waiver Services 88,270$ 18,720 4,833 4.72$ 1.90$Durable Medical Equipment 244,411$ 144,759 37,373 1.69$ 5.26$Lab and X-Ray 214,678$ 11,591 2,992 18.52$ 4.62$Optical 125,545$ 5,492 1,418 22.86$ 2.70$Limited Dental Services 27,337$ 1,095 283 24.96$ 0.59$Transportation 121,057$ 2,188 565 55.32$ 2.60$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 319,152$ 129,568 33,451 2.46$ 6.87$Subtotal (Covered Services) 36,399,475$ 591,580 783.12$

Capitation — PACE -$ - - -$ -$Dental 1,055,528$ 24,009 6,198 43.96$ 22.71$Local Education Agency (LEA) 63,218$ 2,057 531 30.73$ 1.36$Children’s Developmental Services Agencies (CDSA) 135,472$ 5,376 1,388 25.20$ 2.91$Subtotal (Excluded Services) 1,254,218$ 31,442 26.98$Total (All) 37,653,693$ 623,021 810.11$



SFY 2016

Region 5



Non-Duals

All Ages

46,4803,873




137 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 490,877$ 554 240 886.43$ 17.76$Inpatient — BH (LME/MCO) 878,342$ 1,304 566 673.53$ 31.78$Outpatient Hospital 403,008$ 1,325 575 304.19$ 14.58$Emergency Room 408,771$ 1,428 620 286.21$ 14.79$Physician 866,291$ 10,734 4,661 80.71$ 31.35$FQHC/RHC 46,326$ 466 202 99.49$ 1.68$Other Clinic 272,803$ 2,414 1,048 112.99$ 9.87$Other Practitioner 5,326$ 63 27 84.42$ 0.19$Therapies 435,762$ 3,659 1,589 119.08$ 15.77$Prescribed Drugs 4,703,315$ 30,275 13,147 155.35$ 170.20$Enhanced BH 12,322,087$ 106,411 46,209 115.80$ 445.90$B3 Services 25,548$ 5,110 2,219 5.00$ 0.92$LTSS – ICF/IID and Nursing Home 205,941$ 2,102 913 97.96$ 7.45$LTSS – State Plan Home and Community Based Services (HCBS) 101,254$ 7,282 3,162 13.90$ 3.66$LTSS – HCBS Waiver Services 59,217$ 14,115 6,129 4.20$ 2.14$Durable Medical Equipment 258,273$ 88,333 38,358 2.92$ 9.35$Lab and X-Ray 105,763$ 5,663 2,459 18.68$ 3.83$Optical 75,065$ 3,380 1,468 22.21$ 2.72$Limited Dental Services 17,450$ 700 304 24.92$ 0.63$Transportation 70,034$ 1,095 476 63.94$ 2.53$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 196,489$ 78,896 34,260 2.49$ 7.11$Subtotal (Covered Services) 21,947,939$ 365,310 794.24$

Capitation — PACE -$ - - -$ -$Dental 529,978$ 12,495 5,426 42.41$ 19.18$Local Education Agency (LEA) 31,983$ 1,032 448 30.99$ 1.16$Children’s Developmental Services Agencies (CDSA) 87,199$ 3,356 1,457 25.98$ 3.16$Subtotal (Excluded Services) 649,160$ 16,884 23.49$Total (All) 22,597,098$ 382,194 817.73$



SFY 2016

Region 6



Non-Duals

All Ages

27,6342,303




138 of 179



139 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 99,112,418$ 116,576 1,044 850.20$ 73.97$Inpatient — BH (LME/MCO) 68,890,737$ 111,881 1,002 615.75$ 51.42$Outpatient Hospital 54,120,606$ 197,716 1,771 273.73$ 40.39$Emergency Room 65,998,334$ 202,415 1,813 326.05$ 49.26$Physician 88,483,617$ 981,007 8,786 90.20$ 66.04$FQHC/RHC 4,393,960$ 46,480 416 94.53$ 3.28$Other Clinic 9,620,368$ 70,358 630 136.73$ 7.18$Other Practitioner 557,381$ 14,019 126 39.76$ 0.42$Therapies 43,481,108$ 380,348 3,406 114.32$ 32.45$Prescribed Drugs 324,555,658$ 2,263,891 20,275 143.36$ 242.23$Enhanced BH 493,735,520$ 18,253,457 163,479 27.05$ 368.49$B3 Services 62,517,484$ 6,394,350 57,268 9.78$ 46.66$LTSS – ICF/IID and Nursing Home 467,906,493$ 2,162,313 19,366 216.39$ 349.22$LTSS – State Plan Home and Community Based Services (HCBS) 146,164,943$ 35,482,465 317,782 4.12$ 109.09$LTSS – HCBS Waiver Services 620,956,889$ 92,723,949 830,439 6.70$ 463.44$Durable Medical Equipment 53,424,673$ 29,039,764 260,081 1.84$ 39.87$Lab and X-Ray 36,262,785$ 1,623,987 14,544 22.33$ 27.06$Optical 1,476,239$ 69,950 626 21.10$ 1.10$Limited Dental Services 405,155$ 16,269 146 24.90$ 0.30$Transportation 21,141,608$ 914,708 8,192 23.11$ 15.78$Case Management 309,567$ 24,014 215 12.89$ 0.23$Patient-Centered Medical Home (PCMH) Payments 14,724,565$ 3,152,805 28,237 4.67$ 10.99$Subtotal (Covered Services) 2,678,240,109$ 194,242,722 1,998.87$

Capitation — PACE 3,620,577$ 3,070 27 1,179.21$ 2.70$Dental 24,179,695$ 463,970 4,155 52.11$ 18.05$Local Education Agency (LEA) 7,601,679$ 241,298 2,161 31.50$ 5.67$Children’s Developmental Services Agencies (CDSA) 10,075,537$ 412,892 3,698 24.40$ 7.52$Subtotal (Excluded Services) 45,477,489$ 1,121,230 33.94$Total (All) 2,723,717,597$ 195,363,952 2,032.81$



SFY 2016

Statewide



All Eligibles

All Ages

1,339,878111,657




140 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 11,161,234$ 13,067 950 854.12$ 67.59$Inpatient — BH (LME/MCO) 11,249,300$ 12,469 906 902.18$ 68.13$Outpatient Hospital 7,667,151$ 30,965 2,250 247.60$ 46.43$Emergency Room 7,348,451$ 22,734 1,652 323.24$ 44.50$Physician 9,543,695$ 115,903 8,423 82.34$ 57.80$FQHC/RHC 1,201,186$ 10,538 766 113.99$ 7.27$Other Clinic 1,070,335$ 8,504 618 125.86$ 6.48$Other Practitioner 81,512$ 2,119 154 38.47$ 0.49$Therapies 4,546,436$ 41,667 3,028 109.11$ 27.53$Prescribed Drugs 39,977,737$ 300,789 21,859 132.91$ 242.11$Enhanced BH 65,530,618$ 1,753,121 127,404 37.38$ 396.86$B3 Services 2,987,766$ 334,769 24,329 8.92$ 18.09$LTSS – ICF/IID and Nursing Home 36,689,490$ 132,244 9,611 277.44$ 222.19$LTSS – State Plan Home and Community Based Services (HCBS) 12,481,294$ 3,124,622 227,075 3.99$ 75.59$LTSS – HCBS Waiver Services 82,618,400$ 10,965,557 796,896 7.53$ 500.34$Durable Medical Equipment 5,754,071$ 3,156,758 229,410 1.82$ 34.85$Lab and X-Ray 4,619,896$ 180,385 13,109 25.61$ 27.98$Optical 180,948$ 8,769 637 20.64$ 1.10$Limited Dental Services 35,202$ 1,424 103 24.73$ 0.21$Transportation 2,337,034$ 41,825 3,040 55.88$ 14.15$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 1,730,457$ 382,083 27,767 4.53$ 10.48$Subtotal (Covered Services) 308,812,212$ 20,640,313 1,870.18$

Capitation — PACE 2,615,002$ 2,506 182 1,043.38$ 15.84$Dental 3,277,841$ 59,199 4,302 55.37$ 19.85$Local Education Agency (LEA) 1,139,423$ 37,508 2,726 30.38$ 6.90$Children’s Developmental Services Agencies (CDSA) 1,329,262$ 54,644 3,971 24.33$ 8.05$Subtotal (Excluded Services) 8,361,528$ 153,857 50.64$Total (All) 317,173,739$ 20,794,170 1,920.82$



SFY 2016

Region 1



All Eligibles

All Ages

165,12413,760




141 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 15,221,852$ 17,252 1,043 882.32$ 76.70$Inpatient — BH (LME/MCO) 7,944,208$ 12,240 740 649.04$ 40.03$Outpatient Hospital 9,641,826$ 35,456 2,144 271.94$ 48.58$Emergency Room 9,472,268$ 29,424 1,779 321.92$ 47.73$Physician 12,547,040$ 145,075 8,772 86.49$ 63.22$FQHC/RHC 241,023$ 2,441 148 98.73$ 1.21$Other Clinic 1,253,207$ 9,743 589 128.63$ 6.31$Other Practitioner 70,130$ 1,824 110 38.46$ 0.35$Therapies 5,781,642$ 46,570 2,816 124.15$ 29.13$Prescribed Drugs 46,466,288$ 331,248 20,029 140.28$ 234.13$Enhanced BH 65,387,728$ 2,228,054 134,718 29.35$ 329.47$B3 Services 8,045,496$ 725,482 43,866 11.09$ 40.54$LTSS – ICF/IID and Nursing Home 72,977,391$ 345,847 20,911 211.01$ 367.71$LTSS – State Plan Home and Community Based Services (HCBS) 25,471,642$ 6,114,772 369,726 4.17$ 128.34$LTSS – HCBS Waiver Services 109,206,877$ 16,965,873 1,025,831 6.44$ 550.26$Durable Medical Equipment 9,318,404$ 5,164,881 312,291 1.80$ 46.95$Lab and X-Ray 5,259,389$ 238,011 14,391 22.10$ 26.50$Optical 200,322$ 9,833 595 20.37$ 1.01$Limited Dental Services 66,772$ 2,686 162 24.86$ 0.34$Transportation 2,964,164$ 45,921 2,777 64.55$ 14.94$Case Management 15,229$ 1,175 71 12.96$ 0.08$Patient-Centered Medical Home (PCMH) Payments 2,262,921$ 472,742 28,584 4.79$ 11.40$Subtotal (Covered Services) 409,815,819$ 32,946,549 2,064.94$




SFY 2016

Region 2



All Eligibles

All Ages

198,46416,539




142 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 18,421,795$ 25,922 1,038 710.67$ 61.50$Inpatient — BH (LME/MCO) 12,610,722$ 26,017 1,042 484.71$ 42.10$Outpatient Hospital 12,234,478$ 46,443 1,861 263.43$ 40.84$Emergency Room 18,048,772$ 50,214 2,012 359.44$ 60.25$Physician 22,231,073$ 231,191 9,262 96.16$ 74.22$FQHC/RHC 451,914$ 5,397 216 83.74$ 1.51$Other Clinic 2,011,978$ 15,002 601 134.11$ 6.72$Other Practitioner 132,656$ 3,227 129 41.11$ 0.44$Therapies 11,356,372$ 97,706 3,914 116.23$ 37.91$Prescribed Drugs 73,670,307$ 491,404 19,686 149.92$ 245.94$Enhanced BH 96,391,156$ 4,157,314 166,546 23.19$ 321.79$B3 Services 15,615,587$ 1,754,455 70,285 8.90$ 52.13$LTSS – ICF/IID and Nursing Home 84,575,047$ 525,510 21,052 160.94$ 282.35$LTSS – State Plan Home and Community Based Services (HCBS) 34,823,424$ 8,221,152 329,347 4.24$ 116.25$LTSS – HCBS Waiver Services 156,829,349$ 23,638,757 946,990 6.63$ 523.56$Durable Medical Equipment 13,509,188$ 6,267,980 251,101 2.16$ 45.10$Lab and X-Ray 10,893,585$ 473,338 18,962 23.01$ 36.37$Optical 245,684$ 13,205 529 18.61$ 0.82$Limited Dental Services 90,575$ 3,611 145 25.08$ 0.30$Transportation 4,328,970$ 64,942 2,602 66.66$ 14.45$Case Management 98,812$ 7,660 307 12.90$ 0.33$Patient-Centered Medical Home (PCMH) Payments 3,231,246$ 708,574 28,386 4.56$ 10.79$Subtotal (Covered Services) 591,802,691$ 46,829,021 1,975.68$




SFY 2016

Region 3



All Eligibles

All Ages

299,54424,962




143 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 23,291,371$ 25,093 1,083 928.21$ 83.78$Inpatient — BH (LME/MCO) 18,184,318$ 26,996 1,165 673.60$ 65.41$Outpatient Hospital 12,005,233$ 39,879 1,721 301.04$ 43.18$Emergency Room 13,455,204$ 39,954 1,725 336.77$ 48.40$Physician 18,392,733$ 200,979 8,675 91.52$ 66.16$FQHC/RHC 1,078,978$ 11,444 494 94.28$ 3.88$Other Clinic 2,497,416$ 17,260 745 144.69$ 8.98$Other Practitioner 105,558$ 2,525 109 41.81$ 0.38$Therapies 9,174,663$ 80,439 3,472 114.06$ 33.00$Prescribed Drugs 64,076,549$ 441,309 19,048 145.20$ 230.48$Enhanced BH 111,059,453$ 4,207,381 181,606 26.40$ 399.48$B3 Services 25,568,733$ 2,359,436 101,842 10.84$ 91.97$LTSS – ICF/IID and Nursing Home 106,679,399$ 469,514 20,266 227.21$ 383.72$LTSS – State Plan Home and Community Based Services (HCBS) 26,471,136$ 6,639,387 286,580 3.99$ 95.22$LTSS – HCBS Waiver Services 106,943,307$ 15,135,528 653,304 7.07$ 384.67$Durable Medical Equipment 9,714,508$ 5,538,778 239,074 1.75$ 34.94$Lab and X-Ray 7,476,592$ 359,049 15,498 20.82$ 26.89$Optical 282,261$ 13,297 574 21.23$ 1.02$Limited Dental Services 69,265$ 2,782 120 24.90$ 0.25$Transportation 4,026,137$ 145,013 6,259 27.76$ 14.48$Case Management 65,071$ 5,064 219 12.85$ 0.23$Patient-Centered Medical Home (PCMH) Payments 3,022,508$ 642,750 27,743 4.70$ 10.87$Subtotal (Covered Services) 563,640,391$ 36,403,858 2,027.40$




SFY 2016

Region 4



All Eligibles

All Ages

278,01223,168




144 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 16,534,887$ 19,154 1,079 863.26$ 77.62$Inpatient — BH (LME/MCO) 8,894,797$ 15,716 885 565.95$ 41.76$Outpatient Hospital 7,090,651$ 26,122 1,472 271.44$ 33.29$Emergency Room 9,207,959$ 31,906 1,797 288.60$ 43.23$Physician 14,360,940$ 156,816 8,834 91.58$ 67.42$FQHC/RHC 706,475$ 8,435 475 83.75$ 3.32$Other Clinic 1,426,162$ 10,210 575 139.69$ 6.70$Other Practitioner 73,272$ 1,984 112 36.93$ 0.34$Therapies 8,062,934$ 74,757 4,211 107.86$ 37.85$Prescribed Drugs 53,603,052$ 378,894 21,345 141.47$ 251.64$Enhanced BH 87,338,841$ 3,021,732 170,230 28.90$ 410.02$B3 Services 3,570,763$ 423,700 23,869 8.43$ 16.76$LTSS – ICF/IID and Nursing Home 65,889,799$ 312,895 17,627 210.58$ 309.33$LTSS – State Plan Home and Community Based Services (HCBS) 24,171,682$ 5,816,657 327,682 4.16$ 113.48$LTSS – HCBS Waiver Services 90,117,844$ 14,471,259 815,240 6.23$ 423.07$Durable Medical Equipment 8,030,858$ 4,663,462 262,717 1.72$ 37.70$Lab and X-Ray 3,827,734$ 183,697 10,349 20.84$ 17.97$Optical 320,112$ 13,979 788 22.90$ 1.50$Limited Dental Services 71,933$ 2,899 163 24.81$ 0.34$Transportation 3,087,733$ 140,490 7,915 21.98$ 14.50$Case Management 114,708$ 8,900 501 12.89$ 0.54$Patient-Centered Medical Home (PCMH) Payments 2,375,400$ 507,833 28,609 4.68$ 11.15$Subtotal (Covered Services) 408,878,534$ 30,291,497 1,919.52$




SFY 2016

Region 5



All Eligibles

All Ages

213,01117,751




145 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 14,481,279$ 16,088 1,039 900.13$ 77.97$Inpatient — BH (LME/MCO) 10,007,392$ 18,443 1,192 542.62$ 53.88$Outpatient Hospital 5,481,267$ 18,852 1,218 290.76$ 29.51$Emergency Room 8,465,679$ 28,184 1,821 300.37$ 45.58$Physician 11,408,137$ 131,042 8,467 87.06$ 61.43$FQHC/RHC 714,384$ 8,226 531 86.85$ 3.85$Other Clinic 1,361,270$ 9,639 623 141.23$ 7.33$Other Practitioner 94,252$ 2,340 151 40.27$ 0.51$Therapies 4,559,062$ 39,209 2,533 116.28$ 24.55$Prescribed Drugs 46,761,726$ 320,247 20,692 146.02$ 251.78$Enhanced BH 68,027,725$ 2,885,856 186,462 23.57$ 366.29$B3 Services 6,729,139$ 796,508 51,464 8.45$ 36.23$LTSS – ICF/IID and Nursing Home 101,095,367$ 376,304 24,314 268.65$ 544.33$LTSS – State Plan Home and Community Based Services (HCBS) 22,745,767$ 5,565,875 359,624 4.09$ 122.47$LTSS – HCBS Waiver Services 75,241,113$ 11,546,974 746,077 6.52$ 405.13$Durable Medical Equipment 7,097,644$ 4,247,905 274,467 1.67$ 38.22$Lab and X-Ray 4,185,590$ 189,507 12,244 22.09$ 22.54$Optical 246,912$ 10,866 702 22.72$ 1.33$Limited Dental Services 71,408$ 2,867 185 24.91$ 0.38$Transportation 4,397,571$ 476,516 30,789 9.23$ 23.68$Case Management 15,747$ 1,215 79 12.96$ 0.08$Patient-Centered Medical Home (PCMH) Payments 2,102,031$ 438,822 28,353 4.79$ 11.32$Subtotal (Covered Services) 395,290,461$ 27,131,484 2,128.39$

Capitation — PACE -$ - - -$ -$Dental 2,679,461$ 53,570 3,461 50.02$ 14.43$Local Education Agency (LEA) 662,457$ 20,820 1,345 31.82$ 3.57$Children’s Developmental Services Agencies (CDSA) 1,199,518$ 48,824 3,155 24.57$ 6.46$Subtotal (Excluded Services) 4,541,436$ 123,214 24.45$Total (All) 399,831,897$ 27,254,698 2,152.84$



SFY 2016

Region 6



All Eligibles

All Ages

185,72315,477




146 of 179



147 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 26,913,115$ 29,184 5,380 922.19$ 413.42$Inpatient — BH (LME/MCO) 505,453$ 759 140 666.14$ 7.76$Outpatient Hospital 9,877,339$ 29,999 5,530 329.25$ 151.73$Emergency Room 5,430,695$ 10,143 1,870 535.43$ 83.42$Physician 14,348,158$ 114,545 21,115 125.26$ 220.41$FQHC/RHC 286,277$ 2,633 485 108.72$ 4.40$Other Clinic 1,747,165$ 2,133 393 819.08$ 26.84$Other Practitioner 101,332$ 1,437 265 70.51$ 1.56$Therapies 4,875,389$ 40,309 7,430 120.95$ 74.89$Prescribed Drugs 59,412,347$ 439,304 80,980 135.24$ 912.66$Enhanced BH 1,517,023$ 42,179 7,775 35.97$ 23.30$B3 Services 652,291$ 101,690 18,745 6.41$ 10.02$LTSS – ICF/IID and Nursing Home 84,848,730$ 489,279 90,192 173.42$ 1,303.40$LTSS – State Plan Home and Community Based Services (HCBS) 13,404,172$ 2,062,469 380,190 6.50$ 205.91$LTSS – HCBS Waiver Services 129,528,350$ 26,681,542 4,918,408 4.85$ 1,989.74$Durable Medical Equipment 26,039,744$ 8,568,951 1,579,579 3.04$ 400.01$Lab and X-Ray 942,398$ 62,228 11,471 15.14$ 14.48$Optical 114,487$ 3,255 600 35.17$ 1.76$Limited Dental Services 3,801$ 153 28 24.84$ 0.06$Transportation 3,121,629$ 168,806 31,117 18.49$ 47.95$Case Management 3,460$ 267 49 12.96$ 0.05$Patient-Centered Medical Home (PCMH) Payments 685,522$ 113,983 21,011 6.01$ 10.53$Subtotal (Covered Services) 384,358,876$ 38,965,248 5,904.31$




SFY 2016

Statewide



Non-Duals

All Ages

65,0985,425




148 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 3,543,465$ 3,775 5,449 938.68$ 426.20$Inpatient — BH (LME/MCO) 197,631$ 248 358 796.90$ 23.77$Outpatient Hospital 1,310,996$ 5,057 7,299 259.23$ 157.69$Emergency Room 716,268$ 1,346 1,943 531.98$ 86.15$Physician 1,776,333$ 14,528 20,969 122.27$ 213.66$FQHC/RHC 79,113$ 608 878 130.11$ 9.52$Other Clinic 111,211$ 227 328 489.28$ 13.38$Other Practitioner 22,652$ 229 331 98.74$ 2.72$Therapies 571,249$ 5,337 7,703 107.03$ 68.71$Prescribed Drugs 7,526,215$ 60,361 87,122 124.69$ 905.25$Enhanced BH 289,363$ 4,570 6,596 63.32$ 34.80$B3 Services 63,861$ 9,507 13,722 6.72$ 7.68$LTSS – ICF/IID and Nursing Home 10,989,788$ 59,534 85,928 184.60$ 1,321.84$LTSS – State Plan Home and Community Based Services (HCBS) 1,748,289$ 149,541 215,840 11.69$ 210.28$LTSS – HCBS Waiver Services 13,922,773$ 2,879,368 4,155,932 4.84$ 1,674.62$Durable Medical Equipment 2,985,728$ 1,033,133 1,491,171 2.89$ 359.12$Lab and X-Ray 93,998$ 5,516 7,962 17.04$ 11.31$Optical 16,586$ 529 764 31.34$ 1.99$Limited Dental Services 448$ 18 26 24.90$ 0.05$Transportation 341,268$ 12,544 18,105 27.21$ 41.05$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 89,921$ 14,603 21,078 6.16$ 10.82$Subtotal (Covered Services) 46,397,154$ 4,260,581 5,580.61$




SFY 2016

Region 1



Non-Duals

All Ages

8,314693




149 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,479,161$ 5,231 5,898 1,047.39$ 514.77$Inpatient — BH (LME/MCO) 56,504$ 98 110 576.72$ 5.31$Outpatient Hospital 2,179,374$ 5,572 6,281 391.15$ 204.75$Emergency Room 915,525$ 1,727 1,947 530.17$ 86.01$Physician 2,474,321$ 19,421 21,895 127.41$ 232.46$FQHC/RHC 14,912$ 122 138 122.00$ 1.40$Other Clinic 219,016$ 365 411 600.82$ 20.58$Other Practitioner 14,881$ 231 261 64.33$ 1.40$Therapies 467,050$ 3,266 3,682 143.02$ 43.88$Prescribed Drugs 9,075,546$ 75,789 85,444 119.75$ 852.64$Enhanced BH 215,838$ 3,884 4,379 55.57$ 20.28$B3 Services 20,491$ 2,932 3,306 6.99$ 1.93$LTSS – ICF/IID and Nursing Home 13,157,760$ 77,024 86,836 170.83$ 1,236.17$LTSS – State Plan Home and Community Based Services (HCBS) 1,544,716$ 248,079 279,683 6.23$ 145.13$LTSS – HCBS Waiver Services 20,960,504$ 4,174,879 4,706,741 5.02$ 1,969.23$Durable Medical Equipment 4,601,741$ 1,443,969 1,627,925 3.19$ 432.33$Lab and X-Ray 192,667$ 12,498 14,090 15.42$ 18.10$Optical 17,819$ 534 602 33.36$ 1.67$Limited Dental Services 878$ 39 44 22.51$ 0.08$Transportation 426,648$ 15,300 17,249 27.89$ 40.08$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 115,767$ 19,257 21,710 6.01$ 10.88$Subtotal (Covered Services) 62,151,120$ 6,110,217 5,839.08$




SFY 2016

Region 2



Non-Duals

All Ages

10,644887




150 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 5,540,841$ 6,361 4,867 871.00$ 353.26$Inpatient — BH (LME/MCO) 112,633$ 185 142 608.70$ 7.18$Outpatient Hospital 2,517,878$ 6,332 4,844 397.63$ 160.53$Emergency Room 1,340,962$ 2,327 1,780 576.33$ 85.49$Physician 3,500,371$ 30,335 23,208 115.39$ 223.17$FQHC/RHC 21,914$ 220 169 99.46$ 1.40$Other Clinic 367,058$ 500 382 734.48$ 23.40$Other Practitioner 16,800$ 323 247 51.94$ 1.07$Therapies 1,545,907$ 13,072 10,001 118.26$ 98.56$Prescribed Drugs 14,427,184$ 103,342 79,063 139.61$ 919.81$Enhanced BH 394,835$ 13,164 10,071 29.99$ 25.17$B3 Services 96,978$ 12,404 9,490 7.82$ 6.18$LTSS – ICF/IID and Nursing Home 19,383,869$ 115,726 88,538 167.50$ 1,235.82$LTSS – State Plan Home and Community Based Services (HCBS) 3,939,805$ 510,062 390,229 7.72$ 251.18$LTSS – HCBS Waiver Services 36,134,369$ 6,810,292 5,210,297 5.31$ 2,303.75$Durable Medical Equipment 6,826,814$ 2,072,283 1,585,426 3.29$ 435.24$Lab and X-Ray 245,516$ 16,825 12,872 14.59$ 15.65$Optical 21,427$ 609 466 35.17$ 1.37$Limited Dental Services 733$ 25 19 29.30$ 0.05$Transportation 536,265$ 12,259 9,379 43.74$ 34.19$Case Management 1,529$ 118 90 12.96$ 0.10$Patient-Centered Medical Home (PCMH) Payments 169,134$ 28,363 21,700 5.96$ 10.78$Subtotal (Covered Services) 97,142,822$ 9,755,128 6,193.36$

Capitation — PACE 411$ 1 1 411.01$ 0.03$Dental 230,185$ 3,920 2,999 58.71$ 14.68$Local Education Agency (LEA) 202,985$ 7,123 5,449 28.50$ 12.94$Children’s Developmental Services Agencies (CDSA) 41,424$ 1,862 1,425 22.24$ 2.64$Subtotal (Excluded Services) 475,005$ 12,907 30.28$Total (All) 97,617,828$ 9,768,035 6,223.64$



SFY 2016

Region 3



Non-Duals

All Ages

15,6851,307




151 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 3,996,374$ 4,366 4,272 915.24$ 325.84$Inpatient — BH (LME/MCO) 55,739$ 65 64 851.88$ 4.54$Outpatient Hospital 1,643,833$ 5,492 5,373 299.34$ 134.03$Emergency Room 769,531$ 1,542 1,509 498.90$ 62.74$Physician 2,274,584$ 18,644 18,241 122.00$ 185.45$FQHC/RHC 54,920$ 468 458 117.40$ 4.48$Other Clinic 328,298$ 445 435 738.33$ 26.77$Other Practitioner 12,941$ 145 142 89.10$ 1.06$Therapies 1,459,035$ 11,511 11,262 126.75$ 118.96$Prescribed Drugs 10,284,963$ 67,115 65,665 153.24$ 838.56$Enhanced BH 285,384$ 6,625 6,481 43.08$ 23.27$B3 Services 292,259$ 44,750 43,783 6.53$ 23.83$LTSS – ICF/IID and Nursing Home 14,528,066$ 81,983 80,212 177.21$ 1,184.51$LTSS – State Plan Home and Community Based Services (HCBS) 2,540,504$ 402,584 393,886 6.31$ 207.13$LTSS – HCBS Waiver Services 26,494,065$ 5,315,542 5,200,694 4.98$ 2,160.14$Durable Medical Equipment 5,541,271$ 1,935,416 1,893,599 2.86$ 451.80$Lab and X-Ray 142,268$ 9,916 9,702 14.35$ 11.60$Optical 16,554$ 543 532 30.47$ 1.35$Limited Dental Services 782$ 32 31 24.42$ 0.06$Transportation 451,472$ 21,507 21,043 20.99$ 36.81$Case Management 39$ 3 3 12.87$ 0.00$Patient-Centered Medical Home (PCMH) Payments 122,917$ 21,724 21,254 5.66$ 10.02$Subtotal (Covered Services) 71,295,797$ 7,950,419 5,812.95$

Capitation — PACE 200$ 1 1 200.25$ 0.02$Dental 174,539$ 3,196 3,127 54.61$ 14.23$Local Education Agency (LEA) 222,849$ 10,515 10,288 21.19$ 18.17$Children’s Developmental Services Agencies (CDSA) 13,847$ 639 625 21.67$ 1.13$Subtotal (Excluded Services) 411,434$ 14,352 33.55$Total (All) 71,707,231$ 7,964,771 5,846.49$



SFY 2016

Region 4



Non-Duals

All Ages

12,2651,022




152 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,398,155$ 5,145 6,175 854.76$ 439.86$Inpatient — BH (LME/MCO) 39,200$ 75 90 524.98$ 3.92$Outpatient Hospital 1,313,115$ 4,301 5,161 305.32$ 131.32$Emergency Room 827,239$ 1,692 2,030 488.94$ 82.73$Physician 2,388,868$ 17,938 21,528 133.17$ 238.91$FQHC/RHC 50,560$ 519 623 97.46$ 5.06$Other Clinic 341,343$ 307 369 1,110.23$ 34.14$Other Practitioner 16,368$ 258 310 63.35$ 1.64$Therapies 607,956$ 5,212 6,255 116.65$ 60.80$Prescribed Drugs 10,946,432$ 72,658 87,198 150.66$ 1,094.75$Enhanced BH 174,689$ 7,802 9,363 22.39$ 17.47$B3 Services 117,098$ 19,568 23,483 5.98$ 11.71$LTSS – ICF/IID and Nursing Home 13,268,145$ 76,414 91,706 173.64$ 1,326.95$LTSS – State Plan Home and Community Based Services (HCBS) 2,489,687$ 499,837 599,864 4.98$ 248.99$LTSS – HCBS Waiver Services 19,027,783$ 4,647,923 5,578,066 4.09$ 1,902.97$Durable Medical Equipment 3,812,596$ 1,252,050 1,502,611 3.05$ 381.30$Lab and X-Ray 155,074$ 10,014 12,018 15.49$ 15.51$Optical 21,913$ 585 702 37.44$ 2.19$Limited Dental Services 861$ 35 42 24.59$ 0.09$Transportation 578,904$ 31,701 38,046 18.26$ 57.90$Case Management 1,892$ 146 175 12.96$ 0.19$Patient-Centered Medical Home (PCMH) Payments 108,330$ 17,647 21,179 6.14$ 10.83$Subtotal (Covered Services) 60,686,205$ 6,671,829 6,069.23$

Capitation — PACE 7,124$ 2 2 3,561.86$ 0.71$Dental 129,017$ 2,423 2,908 53.24$ 12.90$Local Education Agency (LEA) 146,582$ 9,065 10,879 16.17$ 14.66$Children’s Developmental Services Agencies (CDSA) 28,667$ 1,397 1,677 20.52$ 2.87$Subtotal (Excluded Services) 311,390$ 12,887 31.14$Total (All) 60,997,595$ 6,684,716 6,100.37$



SFY 2016

Region 5



Non-Duals

All Ages

9,999833




153 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 3,955,118$ 4,304 6,306 918.88$ 482.86$Inpatient — BH (LME/MCO) 43,746$ 88 128 499.00$ 5.34$Outpatient Hospital 912,143$ 3,246 4,755 281.01$ 111.36$Emergency Room 861,169$ 1,508 2,210 570.94$ 105.14$Physician 1,933,681$ 13,679 20,040 141.36$ 236.07$FQHC/RHC 64,859$ 696 1,020 93.19$ 7.92$Other Clinic 380,240$ 289 424 1,313.81$ 46.42$Other Practitioner 17,690$ 249 365 70.96$ 2.16$Therapies 224,193$ 1,912 2,801 117.27$ 27.37$Prescribed Drugs 7,152,008$ 60,039 87,958 119.12$ 873.15$Enhanced BH 156,914$ 6,135 8,987 25.58$ 19.16$B3 Services 61,603$ 12,529 18,356 4.92$ 7.52$LTSS – ICF/IID and Nursing Home 13,521,103$ 78,597 115,147 172.03$ 1,650.73$LTSS – State Plan Home and Community Based Services (HCBS) 1,141,171$ 252,365 369,720 4.52$ 139.32$LTSS – HCBS Waiver Services 12,988,857$ 2,853,537 4,180,496 4.55$ 1,585.75$Durable Medical Equipment 2,271,595$ 832,099 1,219,044 2.73$ 277.33$Lab and X-Ray 112,875$ 7,459 10,928 15.13$ 13.78$Optical 20,188$ 454 665 44.45$ 2.46$Limited Dental Services 100$ 4 6 24.90$ 0.01$Transportation 787,072$ 75,495 110,602 10.43$ 96.09$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 79,452$ 12,389 18,150 6.41$ 9.70$Subtotal (Covered Services) 46,685,777$ 4,217,074 5,699.64$

Capitation — PACE -$ - - -$ -$Dental 116,508$ 1,837 2,692 63.42$ 14.22$Local Education Agency (LEA) 52,747$ 1,840 2,696 28.66$ 6.44$Children’s Developmental Services Agencies (CDSA) 7,048$ 445 652 15.84$ 0.86$Subtotal (Excluded Services) 176,303$ 4,122 21.52$Total (All) 46,862,080$ 4,221,196 5,721.17$



SFY 2016

Region 6



Non-Duals

All Ages

8,191683




154 of 179



155 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 17,411,369$ 178,044 839 97.79$ 6.84$Inpatient — BH (LME/MCO) 1,566,235$ 7,651 36 204.71$ 0.62$Outpatient Hospital 33,378,623$ 422,167 1,990 79.06$ 13.11$Emergency Room 25,521,390$ 269,000 1,268 94.88$ 10.02$Physician 51,412,687$ 2,479,880 11,687 20.73$ 20.19$FQHC/RHC 2,528,039$ 106,221 501 23.80$ 0.99$Other Clinic 7,112,974$ 59,043 278 120.47$ 2.79$Other Practitioner 639,911$ 55,081 260 11.62$ 0.25$Therapies 26,865$ 351 2 76.59$ 0.01$Prescribed Drugs 46,948,280$ 515,949 2,432 90.99$ 18.44$Enhanced BH 7,594,385$ 549,944 2,592 13.81$ 2.98$B3 Services 467,596$ 52,417 247 8.92$ 0.18$LTSS – ICF/IID and Nursing Home 596,685,260$ 4,286,111 20,199 139.21$ 234.33$LTSS – State Plan Home and Community Based Services (HCBS) 346,571,919$ 89,879,715 423,578 3.86$ 136.11$LTSS – HCBS Waiver Services 198,457,441$ 61,175,139 288,301 3.24$ 77.94$Durable Medical Equipment 32,341,310$ 27,074,587 127,595 1.19$ 12.70$Lab and X-Ray 1,416,805$ 129,984 613 10.90$ 0.56$Optical 911,372$ 90,562 427 10.06$ 0.36$Limited Dental Services 100$ 4 0 24.90$ 0.00$Transportation 26,588,256$ 1,806,447 8,513 14.72$ 10.44$Case Management 595,583$ 46,087 217 12.92$ 0.23$Patient-Centered Medical Home (PCMH) Payments 25,190,243$ 3,369,304 15,879 7.48$ 9.89$Subtotal (Covered Services) 1,423,366,642$ 192,553,687 558.99$

Capitation — PACE 29,185,556$ 15,053 71 1,938.91$ 11.46$Dental 31,764,993$ 477,916 2,252 66.47$ 12.47$Local Education Agency (LEA) 571$ 25 0 22.83$ 0.00$Children’s Developmental Services Agencies (CDSA) 2,902$ 112 1 25.91$ 0.00$Subtotal (Excluded Services) 60,954,022$ 493,106 23.94$Total (All) 1,484,320,664$ 193,046,793 582.93$



SFY 2016

Statewide

Dual Eligibles


Duals

All Ages

2,546,300212,192




156 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 1,132,391$ 15,081 605 75.09$ 3.79$Inpatient — BH (LME/MCO) 149,019$ 318 13 469.25$ 0.50$Outpatient Hospital 6,398,772$ 59,891 2,404 106.84$ 21.41$Emergency Room 4,354,649$ 28,249 1,134 154.15$ 14.57$Physician 5,020,545$ 267,855 10,753 18.74$ 16.80$FQHC/RHC 558,109$ 19,933 800 28.00$ 1.87$Other Clinic 332,361$ 3,165 127 105.00$ 1.11$Other Practitioner 77,259$ 7,113 286 10.86$ 0.26$Therapies 8,396$ 80 3 104.80$ 0.03$Prescribed Drugs 5,444,375$ 59,680 2,396 91.23$ 18.21$Enhanced BH 976,238$ 43,372 1,741 22.51$ 3.27$B3 Services 27,110$ 3,031 122 8.95$ 0.09$LTSS – ICF/IID and Nursing Home 92,298,709$ 644,407 25,869 143.23$ 308.76$LTSS – State Plan Home and Community Based Services (HCBS) 24,312,217$ 5,484,266 220,156 4.43$ 81.33$LTSS – HCBS Waiver Services 30,999,165$ 9,330,759 374,566 3.32$ 103.70$Durable Medical Equipment 3,150,051$ 2,316,655 92,998 1.36$ 10.54$Lab and X-Ray 131,928$ 13,378 537 9.86$ 0.44$Optical 74,190$ 6,247 251 11.88$ 0.25$Limited Dental Services -$ - - -$ -$Transportation 2,437,114$ 112,889 4,532 21.59$ 8.15$Case Management -$ - - -$ -$Patient-Centered Medical Home (PCMH) Payments 2,724,657$ 366,265 14,703 7.44$ 9.11$Subtotal (Covered Services) 180,607,256$ 18,782,631 604.18$

Capitation — PACE 2,227,784$ 5,771 232 386.05$ 7.45$Dental 3,400,804$ 47,532 1,908 71.55$ 11.38$Local Education Agency (LEA) 523$ 23 1 22.74$ 0.00$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 5,629,112$ 53,326 18.83$Total (All) 186,236,367$ 18,835,957 623.01$



SFY 2016

Region 1

Dual Eligibles


Duals

All Ages

298,93024,911




157 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 3,035,692$ 30,166 847 100.63$ 7.11$Inpatient — BH (LME/MCO) 202,968$ 1,314 37 154.45$ 0.48$Outpatient Hospital 5,229,021$ 92,199 2,590 56.71$ 12.24$Emergency Room 3,702,886$ 43,503 1,222 85.12$ 8.67$Physician 7,570,357$ 372,564 10,466 20.32$ 17.72$FQHC/RHC 64,365$ 2,600 73 24.75$ 0.15$Other Clinic 1,027,795$ 9,523 268 107.93$ 2.41$Other Practitioner 77,438$ 7,774 218 9.96$ 0.18$Therapies 342$ 46 1 7.41$ 0.00$Prescribed Drugs 8,313,907$ 94,305 2,649 88.16$ 19.46$Enhanced BH 999,087$ 61,129 1,717 16.34$ 2.34$B3 Services 14,550$ 1,746 49 8.34$ 0.03$LTSS – ICF/IID and Nursing Home 100,209,224$ 724,472 20,352 138.32$ 234.60$LTSS – State Plan Home and Community Based Services (HCBS) 54,222,707$ 13,716,025 385,319 3.95$ 126.94$LTSS – HCBS Waiver Services 35,410,273$ 10,852,971 304,889 3.26$ 82.90$Durable Medical Equipment 4,837,442$ 3,858,651 108,400 1.25$ 11.32$Lab and X-Ray 296,290$ 25,938 729 11.42$ 0.69$Optical 104,462$ 7,682 216 13.60$ 0.24$Limited Dental Services -$ - - -$ -$Transportation 3,986,000$ 130,145 3,656 30.63$ 9.33$Case Management 67,736$ 5,236 147 12.94$ 0.16$Patient-Centered Medical Home (PCMH) Payments 4,154,021$ 560,056 15,733 7.42$ 9.72$Subtotal (Covered Services) 233,526,564$ 30,598,045 546.70$




SFY 2016

Region 2

Dual Eligibles


Duals

All Ages

427,15835,597




158 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 2,940,009$ 41,432 1,000 70.96$ 5.91$Inpatient — BH (LME/MCO) 104,455$ 1,485 36 70.33$ 0.21$Outpatient Hospital 6,316,171$ 91,319 2,203 69.17$ 12.70$Emergency Room 4,525,373$ 54,680 1,319 82.76$ 9.10$Physician 10,238,856$ 496,593 11,981 20.62$ 20.59$FQHC/RHC 217,730$ 10,635 257 20.47$ 0.44$Other Clinic 1,514,776$ 11,133 269 136.06$ 3.05$Other Practitioner 106,091$ 10,388 251 10.21$ 0.21$Therapies 7,855$ 92 2 85.21$ 0.02$Prescribed Drugs 9,834,860$ 99,721 2,406 98.62$ 19.77$Enhanced BH 1,544,132$ 115,378 2,784 13.38$ 3.10$B3 Services 119,591$ 10,773 260 11.10$ 0.24$LTSS – ICF/IID and Nursing Home 106,095,795$ 789,751 19,054 134.34$ 213.31$LTSS – State Plan Home and Community Based Services (HCBS) 73,363,025$ 18,879,062 455,488 3.89$ 147.50$LTSS – HCBS Waiver Services 35,860,745$ 10,960,063 264,429 3.27$ 72.10$Durable Medical Equipment 6,540,394$ 5,516,227 133,088 1.19$ 13.15$Lab and X-Ray 293,531$ 24,920 601 11.78$ 0.59$Optical 121,901$ 10,181 246 11.97$ 0.25$Limited Dental Services 100$ 4 0 24.90$ 0.00$Transportation 4,757,806$ 133,282 3,216 35.70$ 9.57$Case Management 162,813$ 12,600 304 12.92$ 0.33$Patient-Centered Medical Home (PCMH) Payments 4,724,999$ 630,047 15,201 7.50$ 9.50$Subtotal (Covered Services) 269,391,006$ 37,899,767 541.62$

Capitation — PACE 6,792,475$ 2,225 54 3,052.56$ 13.66$Dental 6,366,381$ 94,415 2,278 67.43$ 12.80$Local Education Agency (LEA) 48$ 2 0 23.88$ 0.00$Children’s Developmental Services Agencies (CDSA) 2,902$ 112 3 25.91$ 0.01$Subtotal (Excluded Services) 13,161,806$ 96,755 26.46$Total (All) 282,552,812$ 37,996,522 568.09$



SFY 2016

Region 3

Dual Eligibles


Duals

All Ages

497,37641,448




159 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 3,704,178$ 31,226 840 118.63$ 8.31$Inpatient — BH (LME/MCO) 380,316$ 1,789 48 212.53$ 0.85$Outpatient Hospital 5,404,602$ 68,829 1,852 78.52$ 12.12$Emergency Room 3,732,556$ 44,032 1,185 84.77$ 8.37$Physician 8,843,507$ 410,871 11,057 21.52$ 19.83$FQHC/RHC 480,242$ 18,295 492 26.25$ 1.08$Other Clinic 1,495,920$ 12,350 332 121.13$ 3.35$Other Practitioner 124,105$ 7,561 203 16.41$ 0.28$Therapies 4,995$ 39 1 127.67$ 0.01$Prescribed Drugs 7,891,239$ 82,233 2,213 95.96$ 17.70$Enhanced BH 1,844,886$ 162,635 4,376 11.34$ 4.14$B3 Services 264,380$ 29,390 791 9.00$ 0.59$LTSS – ICF/IID and Nursing Home 100,952,822$ 711,712 19,152 141.85$ 226.39$LTSS – State Plan Home and Community Based Services (HCBS) 65,134,158$ 17,297,360 465,472 3.77$ 146.06$LTSS – HCBS Waiver Services 24,067,332$ 7,533,061 202,715 3.19$ 53.97$Durable Medical Equipment 5,853,101$ 5,318,772 143,128 1.10$ 13.13$Lab and X-Ray 225,525$ 23,578 634 9.56$ 0.51$Optical 142,612$ 13,455 362 10.60$ 0.32$Limited Dental Services -$ - - -$ -$Transportation 4,792,946$ 288,256 7,757 16.63$ 10.75$Case Management 158,911$ 12,299 331 12.92$ 0.36$Patient-Centered Medical Home (PCMH) Payments 4,076,992$ 550,072 14,802 7.41$ 9.14$Subtotal (Covered Services) 239,575,324$ 32,617,815 537.25$




SFY 2016

Region 4

Dual Eligibles


Duals

All Ages

445,93137,161




160 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 4,040,790$ 34,619 921 116.72$ 8.96$Inpatient — BH (LME/MCO) 516,474$ 1,509 40 342.23$ 1.15$Outpatient Hospital 5,273,768$ 63,389 1,687 83.20$ 11.69$Emergency Room 4,523,036$ 49,820 1,326 90.79$ 10.03$Physician 10,751,835$ 501,099 13,334 21.46$ 23.84$FQHC/RHC 672,714$ 29,423 783 22.86$ 1.49$Other Clinic 1,429,103$ 11,684 311 122.32$ 3.17$Other Practitioner 124,179$ 11,911 317 10.43$ 0.28$Therapies 3,090$ 62 2 49.72$ 0.01$Prescribed Drugs 8,669,445$ 100,877 2,684 85.94$ 19.22$Enhanced BH 1,289,045$ 72,375 1,926 17.81$ 2.86$B3 Services 31,092$ 6,516 173 4.77$ 0.07$LTSS – ICF/IID and Nursing Home 97,143,841$ 691,950 18,413 140.39$ 215.42$LTSS – State Plan Home and Community Based Services (HCBS) 67,087,667$ 17,791,763 473,439 3.77$ 148.77$LTSS – HCBS Waiver Services 39,274,444$ 12,551,571 333,998 3.13$ 87.09$Durable Medical Equipment 5,617,026$ 5,094,760 135,572 1.10$ 12.46$Lab and X-Ray 273,809$ 24,933 663 10.98$ 0.61$Optical 239,965$ 30,670 816 7.82$ 0.53$Limited Dental Services -$ - - -$ -$Transportation 4,874,718$ 322,769 8,589 15.10$ 10.81$Case Management 177,724$ 13,761 366 12.92$ 0.39$Patient-Centered Medical Home (PCMH) Payments 4,592,700$ 611,599 16,275 7.51$ 10.18$Subtotal (Covered Services) 256,606,465$ 38,017,059 569.03$




SFY 2016

Region 5

Dual Eligibles


Duals

All Ages

450,95837,580




161 of 179


Region:


Population Group:

Dual/Non-Dual:

Age:



Unit Cost PMPM

Inpatient — PH 2,558,310$ 25,519 719 100.25$ 6.01$Inpatient — BH (LME/MCO) 213,003$ 1,235 35 172.41$ 0.50$Outpatient Hospital 4,756,290$ 46,541 1,311 102.20$ 11.17$Emergency Room 4,682,889$ 48,716 1,372 96.13$ 10.99$Physician 8,987,587$ 430,898 12,139 20.86$ 21.10$FQHC/RHC 534,879$ 25,335 714 21.11$ 1.26$Other Clinic 1,313,020$ 11,188 315 117.36$ 3.08$Other Practitioner 130,838$ 10,333 291 12.66$ 0.31$Therapies 2,188$ 31 1 70.45$ 0.01$Prescribed Drugs 6,794,453$ 79,133 2,229 85.86$ 15.95$Enhanced BH 940,997$ 95,056 2,678 9.90$ 2.21$B3 Services 10,872$ 963 27 11.29$ 0.03$LTSS – ICF/IID and Nursing Home 99,984,869$ 723,819 20,392 138.14$ 234.74$LTSS – State Plan Home and Community Based Services (HCBS) 62,452,145$ 16,711,240 470,798 3.74$ 146.62$LTSS – HCBS Waiver Services 32,845,482$ 9,946,714 280,224 3.30$ 77.11$Durable Medical Equipment 6,343,296$ 4,969,521 140,004 1.28$ 14.89$Lab and X-Ray 195,721$ 17,237 486 11.35$ 0.46$Optical 228,242$ 22,328 629 10.22$ 0.54$Limited Dental Services -$ - - -$ -$Transportation 5,739,672$ 819,105 23,076 7.01$ 13.48$Case Management 28,398$ 2,191 62 12.96$ 0.07$Patient-Centered Medical Home (PCMH) Payments 4,916,876$ 651,266 18,348 7.55$ 11.54$Subtotal (Covered Services) 243,660,027$ 34,638,370 572.04$

Capitation — PACE -$ - - -$ -$Dental 5,146,328$ 78,456 2,210 65.60$ 12.08$Local Education Agency (LEA) -$ - - -$ -$Children’s Developmental Services Agencies (CDSA) -$ - - -$ -$Subtotal (Excluded Services) 5,146,328$ 78,456 12.08$Total (All) 248,806,355$ 34,716,826 584.13$



SFY 2016

Region 6

Dual Eligibles


Duals

All Ages

425,94735,496




162 of 179


APPENDIX A — BH I/DD TAILORED PLAN DIAGNOSIS CRITERIAThe following tables present an overview of the Behavioral Health (BH) and Intellectual/DevelopmentalDisabilities diagnosis criteria for the following default groups based on condition.· Intellectual/Developmental Disability (I/DD)· Serious and Persistent Mental Illness (SPMI)/Serious Emotional Disturbance (SED)· Substance Use Disorder (SUD)

The list of diagnoses included in these tables was provided to Mercer by the State. Please see section 2.2.3 for afull overview of the criteria used to identify the BH I/DD Tailored Plan population for purposes of the PopulationProfile data report.

163 of 179


I/DD Default Diagnosis

ICD-9 CodesCode Description Code Description

270.10 Classical phenylketonuria 343.10 Spastic hemiplegic cerebral palsy277.50 Hurler's syndrome 343.20 Moderate intellectual disabilities279.11 Di George's syndrome 343.40 Spastic hemiplegic cerebral palsy299.01 Autistic disorder 359.00 Congenital myopathies299.10 Other childhood disintegrative disorder 740.00 Anencephaly299.80 Asperger's syndrome 741.00 Unspecified spina bifida with hydrocephalus299.81 Other pervasive developmental disorders 741.90 Sacral spina bifida without hydrocephalus

299.90 Pervasive developmental disorder,unspecified 742.10 Microcephaly

299.91 Pervasive developmental disorder,unspecified 742.30 Malformations of aqueduct of Sylvius

315.80 Other disorders of psychologicaldevelopment 758.00 Down syndrome, unspecified

315.90 Unspecified disorder of psychologicaldevelopment 758.10 Trisomy 13, unspecified

317.00 Mild intellectual disabilities 758.20 Trisomy 18, unspecified318.00 Moderate intellectual disabilities 758.31 Deletion of short arm of chromosome 5318.10 Severe intellectual disabilities 758.70 Klinefelter syndrome, unspecified318.20 Profound intellectual disabilities 759.50 Tuberous sclerosis

319.00 Unspecified intellectual disabilities 759.81 Congenital malform syndromes predom assoc wshort stature

330.00 Krabbe disease 759.83 Fragile X chromosome330.10 Tay-Sachs disease 759.89 Barth syndrome330.80 Alpers disease 760.71 Newborn affected by maternal use of alcohol343.00 Spastic diplegic cerebral palsy


D82.10 Di George's syndrome F84.90 Pervasive Developmental Disorder, UnspecifiedE70.00 Classical phenylketonuria F88.00 Other disorders of psychological developmentE75.02 Tay-Sachs disease F89.00 unspecified disorder of psychological developmentE75.19 Other Gangliosidosis G31.81 Alpers diseaseE75.23 Krabbe disease G31.82 Leigh's DiseaseE75.25 Metachromatic Leukodystrophy G80.20 Spastic Hemiplegic Cerebral PalsyE75.29 Other Sphingolipidosis Q00.00 AnencephalyE75.40 Neuronal ceroid lipofuscinosis Q02.00 MicrocephalyE76.01 Hurler's syndrome Q03.00 Malformations of aqueduct of SylviusE76.10 Mucopolysaccharidosis, type II Q03.10 Atresia Of Foramina Of Magendie And LuschkaE76.22 Sanfilippo Mucopolysaccharidoses Q03.80 Other congenital hydrocephalusE76.29 Other Mucopolysaccharidoses Q05.40 Unspecified Spina Bifida With HydrocephalusE76.30 Mucopolysaccharidosis, unspecified Q05.80 Sacral spina bifida without hydrocephalusE77.10 Defects In Glycoprotein Degradation Q07.02 Arnold-Chiari Syndrome with Hydrocephalus

164 of 179


Code Description Code Description

E78.71 Barth syndrome Q07.03 Arnold-Chiari Syndrome With Spina Bifida AndHydrocephalus

E78.72 Smith-Lemli-Opitz Syndrome Q85.10 Tuberous sclerosisF70.00 Mild intellectual disabilities Q86.00 Fetal Alcohol Syndrome

F71.00 Moderate intellectual disabilities Q87.10 Congenital Malformation Syndromes with shortstature

F72.00 Severe intellectual disabilities Q87.20 Congenital Malformation SyndromesF73.00 Profound intellectual disabilities Q87.89 Congenital Malformation SyndromesF78.00 Other intellectual disabilities Q90.90 Down Syndrome, UnspecifiedF79.00 Unspecified intellectual disabilities Q91.30 Trisomy 18, unspecifiedF84.00 Autistic Disorder Q91.70 Trisomy 13, unspecifiedF84.20 Rett's Syndrome Q93.40 Deletion of short arm of chromosome 5F84.30 Other childhood disintegrative disorder Q98.40 Klinefelter syndrome, unspecifiedF84.50 Asperger's Syndrome Q99.20 Fragile X ChromosomeF84.80 Other Pervasive Developmental Disorders

165 of 179


SED Diagnosis (Ages 0-17.99)


295.00 Other schizophrenia 296.41 Bipolar disord, crnt episode manic w/o psychfeatures, mild

295.01 Other schizophrenia 296.42 Bipolar disord, crnt episode manic w/o psychfeatures, mod

295.02 Other schizophrenia 296.43 Bipolar disord, crnt epsd manic w/o psych features,severe

295.03 Other schizophrenia 296.44 Bipolar disord, crnt episode manic severe w psychfeatures

295.04 Other schizophrenia 296.45 Bipolar disord, in partial remis, most recent episodemanic

295.05 Other schizophrenia 296.46 Bipolar disorder, in full remis, most recent episodemanic

295.10 Disorganized schizophrenia 296.50 Bipolar disord, crnt epsd depress, mild or modsevert, unsp

295.11 Disorganized schizophrenia 296.51 Bipolar disorder, current episode depressed, mild

295.12 Disorganized schizophrenia 296.52 Bipolar disorder, current episode depressed,moderate

295.13 Disorganized schizophrenia 296.53 Bipolar disord, crnt epsd depress, sev, w/o psychfeatures

295.14 Disorganized schizophrenia 296.54 Bipolar disord, crnt epsd depress, severe, w psychfeatures

295.15 Disorganized schizophrenia 296.55 Bipolar disord, in partial remis, most recent epsddepress

295.20 Catatonic schizophrenia 296.56 Bipolar disorder, in full remis, most recent episodedepress

295.21 Catatonic schizophrenia 296.60 Bipolar disorder, current episode mixed, unspecified295.22 Catatonic schizophrenia 296.61 Bipolar disorder, current episode mixed, mild295.23 Catatonic schizophrenia 296.62 Bipolar disorder, current episode mixed, moderate

295.24 Catatonic schizophrenia 296.63 Bipolar disord, crnt epsd mixed, severe, w/o psychfeatures

295.25 Catatonic schizophrenia 296.64 Bipolar disord, crnt episode mixed, severe, w psychfeatures

295.30 Paranoid schizophrenia 296.65 Bipolar disord, in partial remis, most recent episodemixed

295.31 Paranoid schizophrenia 296.66 Bipolar disorder, in full remis, most recent episodemixed

295.32 Paranoid schizophrenia 296.70 Bipolar disorder, unspecified295.33 Paranoid schizophrenia 296.80 Bipolar disorder, unspecified295.34 Paranoid schizophrenia 296.81 Other manic episodes295.35 Paranoid schizophrenia 296.82 Other depressive episodes295.40 Schizophreniform disorder 296.89 Bipolar II disorder295.41 Schizophreniform disorder 296.90 Unspecified mood [affective] disorder295.42 Schizophreniform disorder 296.99 Other persistent mood [affective] disorders295.43 Schizophreniform disorder 297.00 Delusional disorders295.44 Schizophreniform disorder 297.10 Delusional disorders295.45 Schizophreniform disorder 297.20 Delusional disorders

166 of 179



295.50 Other schizophrenia 297.30 Shared psychotic disorder295.51 Other schizophrenia 297.80 Delusional disorders295.52 Other schizophrenia 297.90 Brief psychotic disorder

295.53 Other schizophrenia 298.00 Major depressv disord, single epsd, severe w psychfeatures

295.54 Other schizophrenia 298.10 Oth psych disorder not due to a sub or knownphysiol cond

295.55 Other schizophrenia 298.20 Other dissociative and conversion disorders295.60 Residual schizophrenia 298.30 Brief psychotic disorder295.61 Residual schizophrenia 298.40 Brief psychotic disorder295.62 Residual schizophrenia 298.80 Brief psychotic disorder

295.63 Residual schizophrenia 298.90 Unsp psychosis not due to a substance or knownphysiol cond

295.64 Residual schizophrenia 299.00 Autistic disorder295.65 Residual schizophrenia 299.01 Autistic disorder295.70 Schizoaffective disorder, unspecified 299.80 Asperger's syndrome295.71 Schizoaffective disorder, unspecified 300.00 Anxiety disorder, unspecified295.72 Schizoaffective disorder, unspecified 300.01 Panic disorder without agoraphobia295.73 Schizoaffective disorder, unspecified 300.02 Generalized anxiety disorder295.74 Schizoaffective disorder, unspecified 300.20 Phobic anxiety disorder, unspecified295.75 Schizoaffective disorder, unspecified 300.21 Agoraphobia with panic disorder295.80 Other schizophrenia 300.22 Agoraphobia without panic disorder295.81 Other schizophrenia 300.23 Social phobia, unspecified295.82 Other schizophrenia 300.29 Other animal type phobia295.83 Other schizophrenia 300.30 Obsessive-compulsive disorder295.84 Other schizophrenia 300.40 Dysthymic disorder295.85 Other schizophrenia 301.12 Dysthymic disorder295.90 Schizophrenia, unspecified 307.10 Anorexia nervosa, unspecified295.91 Schizophrenia, unspecified 307.50 Eating disorder, unspecified295.92 Schizophrenia, unspecified 307.51 Bulimia nervosa295.93 Schizophrenia, unspecified 307.59 Other eating disorders295.94 Schizophrenia, unspecified 309.81 Post-traumatic stress disorder, unspecified

295.95 Schizophrenia, unspecified 311.00 Major depressive disorder, single episode,unspecified

296.00 Manic episode without psychoticsymptoms, unspecified 312.00 Conduct disorder, childhood-onset type

296.01 Manic episode without psychoticsymptoms, mild 312.01 Conduct disorder, childhood-onset type

296.02 Manic episode without psychoticsymptoms, moderate 312.02 Conduct disorder, childhood-onset type

296.03 Manic episode, severe, without psychoticsymptoms 312.03 Conduct disorder, childhood-onset type

296.04 Manic episode, severe with psychoticsymptoms 312.10 Other conduct disorders

296.05 Manic episode in partial remission 312.11 Other conduct disorders

296.06 Manic episode in full remission 312.12 Other conduct disorders

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296.10 Manic episode without psychoticsymptoms, unspecified 312.13 Other conduct disorders

296.11 Manic episode without psychoticsymptoms, mild 312.20 Conduct disorder, adolescent-onset type

296.12 Manic episode without psychoticsymptoms, moderate 312.21 Conduct disorder, adolescent-onset type

296.13 Manic episode, severe, without psychoticsymptoms 312.22 Conduct disorder, adolescent-onset type

296.14 Manic episode, severe with psychoticsymptoms 312.23 Conduct disorder, adolescent-onset type

296.15 Manic episode in partial remission 312.30 Impulse disorder, unspecified296.16 Manic episode in full remission 312.33 Pyromania

296.20 Major depressive disorder, single episode,unspecified 312.34 Intermittent explosive disorder

296.21 Major depressive disorder, single episode,mild 312.39 Trichotillomania

296.22 Major depressive disorder, single episode,moderate 312.40 Other conduct disorders

296.23 Major depressv disord, single epsd, sevw/o psych features 312.81 Conduct disorder, childhood-onset type

296.24 Major depressv disord, single epsd, severew psych features 312.82 Conduct disorder, adolescent-onset type

296.25 Major depressv disorder, single episode, inpartial remis 312.89 Other conduct disorders

296.26 Major depressive disorder, single episode,in full remission 313.00 Other childhood emotional disorders

296.30 Major depressive disorder, recurrent,unspecified 313.81 Oppositional defiant disorder

296.31 Major depressive disorder, recurrent, mild 313.89 Other childhood emotional disorders

296.32 Major depressive disorder, recurrent,moderate 314.00 Attn-defct hyperactivity disorder, predom

inattentive type

296.33 Major depressv disorder, recurrent severew/o psych features 314.01 Attn-defct hyperactivity disorder, predom

hyperactive type

296.34 Major depressv disorder, recurrent, severew psych symptoms 314.10 Attention-deficit hyperactivity disorder, other type

296.35 Major depressive disorder, recurrent, inpartial remission 314.20 Attention-deficit hyperactivity disorder, other type

296.36 Major depressive disorder, recurrent, infull remission 314.80 Attention-deficit hyperactivity disorder, other type

296.40 Bipolar disord, crnt episode manic w/opsych features, unsp 314.90 Attention-deficit hyperactivity disorder, unspecified

type


F06.30 Mood disorder due to known physiologicalcondition, unsp F32.20 Major depressv disord, single epsd, sev w/o psych

features

F06.31 Mood disorder due to known physiol condw depressv features F32.30 Major depressv disord, single epsd, severe w psych

features

F06.32 Mood disord d/t physiol cond w majordepressive-like epsd F32.40 Major depressv disorder, single episode, in partial

remis

F06.80 Oth mental disorders due to knownphysiological condition F32.50 Major depressive disorder, single episode, in full

remission

168 of 179



F09.00 Unsp mental disorder due to knownphysiological condition F32.80 Other depressive episodes

F20.00 Paranoid schizophrenia F32.90 Major depressive disorder, single episode,unspecified

F20.10 Disorganized schizophrenia F33.00 Major depressive disorder, recurrent, mildF20.20 Catatonic schizophrenia F33.10 Major depressive disorder, recurrent, moderate

F20.30 Undifferentiated schizophrenia F33.20 Major depressv disorder, recurrent severe w/opsych features

F20.50 Residual schizophrenia F33.30 Major depressv disorder, recurrent, severe w psychsymptoms

F20.81 Schizophreniform disorder F33.40 Major depressive disorder, recurrent, in remission,unsp

F20.89 Other schizophrenia F33.41 Major depressive disorder, recurrent, in partialremission

F20.90 Schizophrenia, unspecified F33.42 Major depressive disorder, recurrent, in fullremission

F22.00 Delusional disorders F33.80 Other recurrent depressive disordersF23.00 Brief psychotic disorder F33.90 Major depressive disorder, recurrent, unspecifiedF24.00 Shared psychotic disorder F34.10 Dysthymic disorderF25.00 Schizoaffective disorder, bipolar type F34.80 Other persistent mood [affective] disordersF25.10 Schizoaffective disorder, depressive type F34.90 Persistent mood [affective] disorder, unspecifiedF25.80 Other schizoaffective disorders F39.00 Unspecified mood [affective] disorderF25.90 Schizoaffective disorder, unspecified F40.00 Agoraphobia, unspecified

F28.00 Oth psych disorder not due to a sub orknown physiol cond F40.01 Agoraphobia with panic disorder

F29.00 Unsp psychosis not due to a substance orknown physiol cond F40.02 Agoraphobia without panic disorder

F30.10 Manic episode without psychoticsymptoms, unspecified F40.10 Social phobia, unspecified

F30.11 Manic episode without psychoticsymptoms, mild F40.11 Social phobia, generalized

F30.12 Manic episode without psychoticsymptoms, moderate F40.80 Other phobic anxiety disorders

F30.13 Manic episode, severe, without psychoticsymptoms F41.00 Panic disorder without agoraphobia

F30.20 Manic episode, severe with psychoticsymptoms F41.10 Generalized anxiety disorder

F30.30 Manic episode in partial remission F41.30 Other mixed anxiety disordersF30.40 Manic episode in full remission F41.80 Other specified anxiety disordersF30.80 Other manic episodes F41.90 Anxiety disorder, unspecifiedF30.90 Manic episode, unspecified F42.00 Obsessive-compulsive disorder

F31.00 Bipolar disorder, current episodehypomanic F43.10 Post-traumatic stress disorder, unspecified

F31.10 Bipolar disord, crnt episode manic w/opsych features, unsp F43.12 Post-traumatic stress disorder, chronic

F31.11 Bipolar disord, crnt episode manic w/opsych features, mild F44.89 Other dissociative and conversion disorders

F31.12 Bipolar disord, crnt episode manic w/opsych features, mod F50.00 Anorexia nervosa, unspecified

169 of 179



F31.13 Bipolar disord, crnt epsd manic w/o psychfeatures, severe F50.01 Anorexia nervosa, restricting type

F31.20 Bipolar disord, crnt episode manic severew psych features F50.02 Anorexia nervosa, binge eating/purging type

F31.30 Bipolar disord, crnt epsd depress, mild ormod severt, unsp F50.20 Bulimia nervosa

F31.31 Bipolar disorder, current episodedepressed, mild F50.80 Other eating disorders

F31.32 Bipolar disorder, current episodedepressed, moderate F50.90 Eating disorder, unspecified

F31.40 Bipolar disord, crnt epsd depress, sev, w/opsych features F63.10 Pyromania

F31.50 Bipolar disord, crnt epsd depress, severe,w psych features F63.30 Trichotillomania

F31.60 Bipolar disorder, current episode mixed,unspecified F63.81 Intermittent explosive disorder

F31.61 Bipolar disorder, current episode mixed,mild F63.89 Other impulse disorders

F31.62 Bipolar disorder, current episode mixed,moderate F84.00 Autistic disorder

F31.63 Bipolar disord, crnt epsd mixed, severe,w/o psych features F84.50 Asperger's syndrome

F31.64 Bipolar disord, crnt episode mixed, severe,w psych features F90.00 Attn-defct hyperactivity disorder, predom

inattentive type

F31.70 Bipolar disord, currently in remis, mostrecent episode unsp F90.10 Attn-defct hyperactivity disorder, predom

hyperactive type

F31.71 Bipolar disord, in partial remis, most recentepsd hypomanic F90.20 Attention-deficit hyperactivity disorder, combined

type

F31.72 Bipolar disord, in full remis, most recentepisode hypomanic F90.80 Attention-deficit hyperactivity disorder, other type

F31.73 Bipolar disord, in partial remis, most recentepisode manic F90.90 Attention-deficit hyperactivity disorder, unspecified

type

F31.74 Bipolar disorder, in full remis, most recentepisode manic F91.00 Conduct disorder confined to family context

F31.75 Bipolar disord, in partial remis, most recentepsd depress F91.10 Conduct disorder, childhood-onset type

F31.76 Bipolar disorder, in full remis, most recentepisode depress F91.20 Conduct disorder, adolescent-onset type

F31.77 Bipolar disord, in partial remis, most recentepisode mixed F91.30 Oppositional defiant disorder

F31.78 Bipolar disorder, in full remis, most recentepisode mixed F91.80 Other conduct disorders

F31.81 Bipolar II disorder F91.90 Conduct disorder, unspecifiedF31.89 Other bipolar disorder F94.10 Reactive attachment disorder of childhoodF31.90 Bipolar disorder, unspecified F94.20 Disinhibited attachment disorder of childhood

F32.00 Major depressive disorder, single episode,mild F98.80 Oth behav/emotn disord w onset usly occur in

chldhd and adol

F32.10 Major depressive disorder, single episode,moderate F99.00 Mental disorder, not otherwise specified

170 of 179


SPMI Diagnosis (Ages 18+)


295.40 Schizophreniform disorder 296.50 Bipolar disord, crnt epsd depress, mild or modsevert, unsp

295.70 Schizoaffective disorder, unspecified 296.51 Bipolar disorder, current episode depressed, mild

295.90 Schizophrenia, unspecified 296.52 Bipolar disorder, current episode depressed,moderate

296.20 Major depressive disorder, single episode,unspecified 296.53 Bipolar disord, crnt epsd depress, sev, w/o psych

features

296.21 Major depressive disorder, single episode,mild 296.54 Bipolar disord, crnt epsd depress, severe, w psych

features

296.22 Major depressive disorder, single episode,moderate 296.55 Bipolar disord, in partial remis, most recent epsd

depress

296.23 Major depressv disord, single epsd, sevw/o psych features 296.70 Bipolar disorder, unspecified

296.24 Major depressv disord, single epsd, severew psych features 296.80 Bipolar disorder, unspecified

296.25 Major depressv disorder, single episode, inpartial remis 296.89 Bipolar II disorder

296.30 Major depressive disorder, recurrent,unspecified 298.90 Unsp psychosis not due to a substance or known

physiol cond296.31 Major depressive disorder, recurrent, mild 300.01 Panic disorder without agoraphobia

296.32 Major depressive disorder, recurrent,moderate 300.02 Generalized anxiety disorder

296.33 Major depressv disorder, recurrent severew/o psych features 300.12 Dissociative amnesia

296.34 Major depressv disorder, recurrent, severew psych symptoms 300.13 Dissociative fugue

296.35 Major depressive disorder, recurrent, inpartial remission 300.14 Dissociative identity disorder

296.40 Bipolar disord, crnt episode manic w/opsych features, unsp 300.15 Dissociative and conversion disorder, unspecified

296.41 Bipolar disord, crnt episode manic w/opsych features, mild 300.22 Agoraphobia without panic disorder

296.42 Bipolar disord, crnt episode manic w/opsych features, mod 300.30 Obsessive-compulsive disorder

296.43 Bipolar disord, crnt epsd manic w/o psychfeatures, severe 301.22 Schizotypal disorder

296.44 Bipolar disord, crnt episode manic severew psych features 309.81 Post-traumatic stress disorder, unspecified

296.45 Bipolar disord, in partial remis, most recentepisode manic


F20.81 Schizophreniform disorder F32.10 Major depressive disorder, single episode, moderate

F20.90 Schizophrenia, unspecified F32.20 Major depressv disord, single epsd, sev w/o psychfeatures

F21.00 Schizotypal disorder F32.30 Major depressv disord, single epsd, severe w psychfeatures

171 of 179



F25.00 Schizoaffective disorder, bipolar type F32.40 Major depressv disorder, single episode, in partialremis

F25.10 Schizoaffective disorder, depressive type F32.90 Major depressive disorder, single episode,unspecified

F29.00 Unsp psychosis not due to a substance orknown physiol cond F33.00 Major depressive disorder, recurrent, mild

F31.00 Bipolar disorder, current episodehypomanic F33.10 Major depressive disorder, recurrent, moderate

F31.11 Bipolar disord, crnt episode manic w/opsych features, mild F33.20 Major depressv disorder, recurrent severe w/o

psych features

F31.12 Bipolar disord, crnt episode manic w/opsych features, mod F33.30 Major depressv disorder, recurrent, severe w psych

symptoms

F31.13 Bipolar disord, crnt epsd manic w/o psychfeatures, severe F33.41 Major depressive disorder, recurrent, in partial

remission

F31.20 Bipolar disord, crnt episode manic severew psych features F33.90 Major depressive disorder, recurrent, unspecified

F31.31 Bipolar disorder, current episodedepressed, mild F40.00 Agoraphobia, unspecified

F31.32 Bipolar disorder, current episodedepressed, moderate F41.00 Panic disorder without agoraphobia

F31.40 Bipolar disord, crnt epsd depress, sev, w/opsych features F41.10 Generalized anxiety disorder

F31.50 Bipolar disord, crnt epsd depress, severe,w psych features F42.00 Obsessive-compulsive disorder

F31.73 Bipolar disord, in partial remis, most recentepisode manic F43.10 Post-traumatic stress disorder, unspecified

F31.75 Bipolar disord, in partial remis, most recentepsd depress F44.00 Dissociative amnesia

F31.81 Bipolar II disorder F44.10 Dissociative fugueF31.89 Other bipolar disorder F44.81 Dissociative identity disorderF31.90 Bipolar disorder, unspecified F44.89 Other dissociative and conversion disorders

F32.00 Major depressive disorder, single episode,mild F44.90 Dissociative and conversion disorder, unspecified

172 of 179


SUD Diagnosis Code ListSUD Non-Severe Diagnosis Code List


291.00 Alcohol dependence with withdrawaldelirium 305.40 Sedative, hypnotic or anxiolytic abuse,

uncomplicated

291.81 Alcohol dependence with withdrawal,unspecified 305.50 Opioid abuse, uncomplicated

292.00 Other psychoactive substance use, unspwith withdrawal, unsp 305.60 Cocaine abuse, uncomplicated

305.00 Alcohol abuse, uncomplicated 305.70 Other stimulant abuse, uncomplicated305.20 Cannabis abuse, uncomplicated 305.90 Inhalant abuse, uncomplicated

305.30 Hallucinogen abuse, uncomplicated


F10.10 Alcohol abuse, uncomplicated F13.10 Sedative, hypnotic or anxiolytic abuse,uncomplicated

F10.121 Alcohol abuse with intoxication delirium F13.231 Sedatv/hyp/anxiolytc dependence w withdrawaldelirium

F10.221 Alcohol dependence with intoxicationdelirium F13.232 Sedatv/hyp/anxiolytc depend w w/drawal w

perceptual disturb

F10.231 Alcohol dependence with withdrawaldelirium F13.239 Sedatv/hyp/anxiolytc dependence w withdrawal,

unsp

F10.232 Alcohol dependence w withdrawal withperceptual disturbance F14.10 Cocaine abuse, uncomplicated

F10.239 Alcohol dependence with withdrawal,unspecified F14.23 Cocaine dependence with withdrawal

F10.921 Alcohol use, unspecified with intoxicationdelirium F15.10 Other stimulant abuse, uncomplicated

F11.10 Opioid abuse, uncomplicated F15.23 Other stimulant dependence with withdrawal

F11.120 Opioid abuse with intoxication,uncomplicated F15.929 Other stimulant use, unsp with intoxication,

unspecifiedF11.129 Opioid abuse with intoxication, unspecified F15.93 Other stimulant use, unspecified with withdrawalF11.23 Opioid dependence with withdrawal F16.10 Hallucinogen abuse, uncomplicatedF11.90 Opioid use, unspecified, uncomplicated F17.203 Nicotine dependence unspecified, with withdrawalF11.93 Opioid use, unspecified with withdrawal F18.10 Inhalant abuse, uncomplicatedF12.10 Cannabis abuse, uncomplicated F19.10 Other psychoactive substance abuse, uncomplicated

F12.288 Cannabis dependence with other cannabis-induced disorder F19.231 Oth psychoactive substance dependence w

withdrawal delirium

F12.90 Cannabis use, unspecified, uncomplicated F19.239 Oth psychoactive substance dependence withwithdrawal, unsp

SUD Dependence-Level Diagnosis Code List


303.9 Alcohol dependence, uncomplicated 304.4 Other stimulant dependence, uncomplicated

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304.0 Opioid dependence, uncomplicated 304.5 Hallucinogen dependence, uncomplicated

304.1 Sedative, hypnotic or anxiolyticdependence, uncomplicated 304.6 Other psychoactive substance dependence,

uncomplicated

304.2 Cocaine dependence, uncomplicated 304.8 Other psychoactive substance dependence,uncomplicated

304.3 Cannabis dependence, uncomplicated


F10.20 Alcohol dependence, uncomplicated F19.220 Oth psychoactive substance dependence wintoxication, uncomp

F11.20 Opioid dependence, uncomplicated F19.24 Oth psychoactive substance dependence w mooddisorder

F12.20 Cannabis dependence, uncomplicated F19.259 Oth psychoactv substance depend w psychoticdisorder, unsp

F13.20 Sedative, hypnotic or anxiolyticdependence, uncomplicated F19.26 Oth psychoactv substance depend w persist

amnestic disorder

F14.20 Cocaine dependence, uncomplicated F19.280 Oth psychoactive substance dependence w anxietydisorder

F15.20 Other stimulant dependence,uncomplicated F19.281 Oth psychoactive substance dependence w sexual

dysfunction

F16.20 Hallucinogen dependence, uncomplicated F19.282 Oth psychoactive substance dependence w sleepdisorder

F18.20 Inhalant dependence, uncomplicated F19.288 Oth psychoactive substance dependence w othdisorder

F19.20 Other psychoactive substancedependence, uncomplicated F19.29 Oth psychoactive substance dependence w unsp

disorder

F19.21 Other psychoactive substancedependence, in remission

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APPENDIX B — CATEGORY OF SERVICE (COS) MAPPING LOGICThe following tables represent the mapping logic used to define the detail COS. The FFS data detailed COS isbased on a combination of claim type and state-defined categories based on provider taxonomy. The encounterdata detailed COS is based on logic defined and used for the development of the LME/MCO capitation rates.

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COS Mapping LogicThe COS are assigned in a hierarchy, as outlined in the tables below.

Excluded ServicesCOS Description Data Source Coding LogicCapitation FFS "Claim_Type '4'

This excludes the following capitation payments:MedSolutions, PACE, BH LME Capitation, Innovations LMECapitation"

Dental FFS "Claim_Type 'D' OR(Procedure codes with first character 'D', but NOT [(D0145OR D1206) AND not claim type D])

Local Education Agency FFS Claim_Type '0'Children's Developmental Services Agencies FFS Claim_Type 'V'

Covered ServicesCOS Description COS Detailed

DescriptionData Source Coding Logic

PCMH Payments PCMH Payments FFS Claim_Type 'M'Therapies Therapies FFS Claim_type '2'Dental (limited) Dental (limited) FFS Procedure codes D0145 OR D1206, when billed without

claim type ‘D’Inpatient - PH Inpatient - PH FFS [State COS = 0015 (HOSP INPT-GENERAL) OR

0019 (HOSP INPT-SPECIALITY) OR0051 (HOSP INPT-GEN XOVERS) OR0040 (HOSP INPT-INDIAN)]

Inpatient - BH Inpatient - BH LME/MCOEncounters

Revenue code 101–182, 184–219

Emergency Room Emergency Room FFS Revenue code 0450 - 0459 OR CPT codes 99281 - 99285State COS = 0050 (HOSP OUTPT-EMER. ROOM)Note: If claim has Inpatient bill type, dollars should beassigned to Inpatient regardless of Emergency Roomrevenue code or Emergency Room State COS.

LME/MCOEncounters

Revenue code 0450 - 0459 OR CPT codes 99281 - 99285Note: If claim has Inpatient bill type, dollars should beassigned to Inpatient regardless of Emergency Roomrevenue code.

Outpatient Hospital Outpatient Hospital -PH

FFS [State COS = 0016 (HOSP OUTPT-GENERAL) OR0045 (HOSP OUTPT-SPECIALITY) OR0048 (AMBULATORY SURG CENTER) OR0052 (HOSP OUTPT-GEN XOVERS) OR0042 (HOSP OUTPT-INDIAN)]AND NOT ICD9 290-319 OR ICD10 Fxx codes

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COS Description COS DetailedDescription

Data Source Coding Logic

Outpatient Hospital -BH

Outpatient Hospital -BH

FFS [State COS = 0016 (HOSP OUTPT-GENERAL) OR0045 (HOSP OUTPT-SPECIALITY) OR0048 (AMBULATORY SURG CENTER) OR0052 (HOSP OUTPT-GEN XOVERS) OR0042 (HOSP OUTPT-INDIAN)]AND ICD9 290-319 OR ICD10 Fxx codes

LME/MCOEncounters

Procedure codes 90785, 90791, 90792, 90801–90899,96100, 96101, 96110, 96111, 96115–96118, G0431, G0434,H0001, H0002, H0004, H0005, H0010, H0012–H0015,H0020, H0031, H2035, Q3014, S9485, T1023, covered E/Mcodes (99xxx) or Revenue codes 450–459, 900–910, 912–919

LTSS - ICF/IID andNursing Home

ICF/IID FFS State COS = 0021 (LTC-ICF MRC, SO) OR0047 (LTC-ICF MRC, NSO)

LME/MCOEncounters

Revenue code 100 or 183

Nursing Home FFS State COS = 0020 (LTC-ICF SO AND NSO) OR0022 (NF-ICF SWING BEDS) OR0035 (LTC-SNF SO AND NSO) OR0036 (NF-SNF SWING BEDS) OR0039 (NF-INDIAN HEALTH) OR0049 (HOSP LONG TERM CARE) OR0071 (NF-HEAD LEVEL OF CARE) OR0072 (NF-VENT LEVEL OF CARE)

Enhanced MentalHealth

PRTF FFS State COS = 0017 (HOSP INPT-MTL,SO < 21) OR0041 (HOSP INPT-MTL,NSO < 21)

LME/MCOEncounters

Revenue code 911

Other BehavioralHealth Services

FFS State COS = 0070 (PRACTITIONER-NON PHYS) OR0084 (HIGH RISK INTERVENTION)

ACT LME/MCOEncounters

Procedure code H0040

Community Support LME/MCOEncounters

Procedure code H0036, [H2015 AND COA other thanInnovations]

Crisis Services LME/MCOEncounters

Procedure code S9484, [H2011 AND COA other thanInnovations]

IIHS LME/MCOEncounters


MST LME/MCOEncounters


Outpatient (includingpsychotherapy andlimited alcohol/drugservices)

LME/MCOEncounters

Procedure codes 90785, 90791, 90792, 90801–90899,96100, 96101, 96110, 96111, 96115–96118, G0431, G0434,H0001, H0002, H0004, H0005, H0010, H0012–H0015,H0020, H0031, H2035, Q3014, S9485, T1023, covered E/Mcodes (99xxx) or Revenue codes 450–459, 900–910, 912–919

Partial Hosp/Day Tx LME/MCOEncounters

Procedure code H0035, H2012

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Psych Rehab LME/MCOEncounters


BH Long-termResidential

LME/MCOEncounters

Procedure code H0019, H0046, H2020, S5145

Physician - PrimaryCare

Physician - PrimaryCare

FFS State COS = 0027 (PHYSICIAN) ANDTaxonomy_Codes = 207Q00000X, 207RA0000X,208000000X, 2080A0000X, 208D00000X, 363A00000X,363L00000X, 363LF0000X

Physician - Specialty Physician - Specialty FFS State COS = 0027 (PHYSICIAN) without the taxonomyrestriction on Physician Primary Care.

FQHC/RHC FQHC/RHC FFS State COS = 0006 (CLINICS-RURAL HEALTH) OR0061 (HEALTH CHECK-RURAL HLT) OR0065 (CLINICS-FQHC,CORE&AMB) OR0067 (HEALTH CHECK-FQHC) OR[SCOS 0073 (OTHER AMB CARE-INDIAN) AND Claim_Type '5'(RURAL HLTH CLINIC / FEDERALLY QUALIFIED HLTH CNTR)]

Other Clinic Free-standingClinics/Health Check -Health Department

FFS State COS = 0002 (CLINICS-FREE STANDING) OR0003 (CLINICS-HEALTH DEPT) OR0033 (HEALTH CHECK-HLTH DEPT) OR0034 (HEALTH CHECK-OTHR PROV) OR[SCOS 0073 (OTHER AMB CARE-INDIAN) AND NOT(Claim_Type '3' (INSTITUTIONAL AMBULANCE) ORClaim_Type 'T' (AMBULANCE (PROFESSIONAL)))]

Family PlanningServices

FFS State COS = 0010 (FAMILY PLAN-HOSP INPT) OR0011 (FAMILY PLAN-HOSP OUTPT) OR0012 (FAMILY PLAN-PHYSICIAN) OR0024 (FAMILY PLAN-STERILIZATION) OR0031 (FAMILY PLAN-DRUGS) OR0037 (FAMILY PLAN-RURAL HLTH) OR0038 (FAMILY PLAN-HLTH DEPT) OR0066 (FAMILY PLAN-FQHC)

Other Practitioner Other Practitioner FFS State COS = 0028 (CHIROPRACTIC) OR0046 (PODIATRY)

Case Management Case Management FFS State COS = 0062 (CASE MANAGEMENT-FSO) OR0081 (CASE MANAGEMENT-HIV)

LTSS - State PlanHCBS

Home Health FFS State COS = 0014 (HOME HEALTH) OR0026 (HOME HEALTH-INDIAN) OR0059 (HOME INFUSION THERAPY)

Personal Care FFS State COS = 0053 (PERSONAL CARE)Hospice FFS State COS = 0060 (HOSPICE)

LTSS - HCBS WaiverServices

HCBS Services - FFS FFS State COS = 0055 (CAP-DISABLED) OR0057 (CAP-CHILDREN) OR0085 (CAP CHOICE)

Innovations - DaySupport

LME/MCOEncounters

Procedure code T2021, T2027

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Innovations - In-Home Services

LME/MCOEncounters

Procedure code H2015, T1015, T2013

Innovations -Personal Care

LME/MCOEncounters

Procedure code S5125, T1019

Innovations -Residential Supports

LME/MCOEncounters

Procedure code H2016, T2014, T2016, T2020

Innovations - Respite LME/MCOEncounters

Procedure code H0045, S5150, T1005

Innovations -SupportedEmployment

LME/MCOEncounters

Procedure code H2023, H2025, H2026

Innovations - Other LME/MCOEncounters

Procedure code H2011, S5110, S5111, S5165, T1999, T2025,T2029, T2034, T2038, T2039, T2041 or [B4100–B4162 AND[age_group] = 21+]

FFS InnovationsServices

FFS State COS = 0056 (CAP-MENTALLY RETARDED)

B3 Services B3 Services LME/MCOEncounters

Procedure code 99241 U4, 99242 U4, 99244 U4, H0038,S5151, T1012, H2022 U4, [(H0045, H2016, H2023, H2025-H2026, S5110, S5111, S5125, S5150, S5165, T1005, T1015,T1019, T2013, T2014, T2020, T2021, T2025, T2027, T2029,T2034, T2038, T2039 or T2041) AND COA other thanInnovations]

Prescribed Drugs Prescribed Drugs FFS State COS = 0032 (PRESCRIBED DRUGS)Durable MedicalEquipment

Durable MedicalEquipment

FFS State COS = 0013 (HEARING AIDS) OR0054 (DURABLE MEDICAL EQUIP)

Optical Optical FFS State COS = 0029 (OPTICAL SUPPLIES) OR0030 (OPTICAL)

Lab and X-ray Lab and X-ray FFS State COS = 0023 (LAB AND X-RAY)Transportation Transportation FFS State COS = 0001 (AMBULANCE) OR

[SCOS 0073 (OTHER AMB CARE-INDIAN) AND (Claim_Type'3' (INSTITUTIONAL AMBULANCE) OR Claim_Type 'T'(AMBULANCE (PROFESSIONAL)))]

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